Oxford County Claim/Incident Reporting Form

Note: There is a 10 day notice period for providing the County with Notice of certain types of claims and a two year limitation period for bringing an action in respect to most claims against the County.

We suggest that in all cases of loss or damage you contact your insurance company or broker. Depending on the type of property damaged, and the insurance policy you purchased, you may be eligible for compensation from your insurance company.

Reporter Details

"Reporter" is the person filling out this form.

Are you an employee for the County of Oxford?

Involvement Type

First Name	Last Name
Email	Phone
Mobile Phone

Mailing Street	Mailing City
Mailing State/Province	Mailing Country
Mailing Zip/Postal Code

Did this person sustain an Injury?

Description of Personal Injuries

Have you claimed compensation from your insurance provider? If yes, please provide details below.

Claimant Claim Number

Claimant Insurance Company

Incident/Claim Information

Incident Date/Time

AM/PM

Incident Address	Incident City
Incident State/Province	Incident Country

Were any vehicles involved in the incident?

Were any properties involved in the incident?

Incident Description

Emergency Personnel Attended

Badge Number

Occurrence Number and Police Service

Action Taken

Involved Persons

"Involved Person" is an individual who is/may be involved with the claim/incident (directly or indirectly) being reported. (Examples include the claimant, witness to the incident, lawyer, employees, visitors, volunteers, etc.)

Do you wish to add "Involved Persons" to this report?

Involved Person Details

Involvement Type

Adjuster Number

First Name	Last Name
Email

Phone	Mobile Phone
Mailing Street	Mailing City
Mailing State/Province	Mailing Country
Mailing Zip/Postal Code

Sustained Injury?

Description of Personal Injuries

To add another involved person, please select "Add another involved person" on the bottom-right portion of this section. This will open another section where information can inserted. If not required, please ignore.

Follow-Up and Corrective Actions

Follow-Up Completed By:

What was the person doing?

How can a similar occurrence be prevented?

Lessons learned to prevent injuries

Action Taken

Additional Notes

Involved Vehicle

Vehicle Type

Was this a County Vehicle?	Unit Number
Vehicle Color	Vehicle Make
Vehicle Model	Vehicle Year
Vehicle License Plate Number	Vehicle VIN

Description of Damages

To add another vehicle, please select "Add another vehicle" on the bottom-right portion of this section.

Involved Property

Was this a County Property?

Property Name

Property Address

Description of Damages

To add another property, please select "Add another property" on the bottom-right portion of this section.

Attachments

Do you wish to add Files/Attachments?

Note: There is a 25 MB per file size limit, a 35 MB total file size limit, and a 10 file limit per submission.

Please upload any supporting documents, images, invoices, or estimate of damages.

File Upload

To add more than one attachment, select "Add another attachment". To remove the additional file upload option, select "Remove".

Declaration

The information provided herein is true. I understand that submitting false statements and/or documentation is a form of fraud and is illegal. I acknowledge that fraudulent claims cost taxpayers, and that claims that are determined to be made fraudulently will be prosecuted to the full extent of the law.

I hereby give consent to County of Oxford to collect, use or disclose my information that is necessary and reasonable for the purposes of processing my claim.

I accept that County of Oxford will disclose my personal information to the County’s insurance adjuster and/or to those involved in the resulting claim resolution, including but not limited to lawyers, or third parties that are found responsible for losses claimed.

Personal information on this form is collected under the authority of the Municipal Act 2001 C.25 and will be used to process your claim with County of Oxford. Questions about this collection may be directed to:

Coordinator of Legislative Services

at 519-539-9800 ext 3017

clerksoffice@oxfordcounty.ca

I have read, acknowledge and understand the consequences and agree with the statement above

I agree

NOTE: If you do not agree, the County of Oxford is unable to accept your online form as notice about your claim.