City of Sarnia Incident Report Form

Designation


Any information which you provide on this on-line form will be kept confidential. 

Personal information is collected under the authority of the Municipal Act and Insurance Act of Ontario and is used to process insurance claims. For further information, please contact Legal Services via email at legal@sarnia.ca 

Contact Information


THE CORPORATION OF THE CITY OF SARNIA 

Legal Department 

255 Christina Street N. PO Box 3018 

Sarnia, ON Canada N7T 7N2 

519-332-0330 (phone) 519-332-3995 (fax) 

legal@sarnia.ca
Contact Information


THE CORPORATION OF THE CITY OF SARNIA 

HR Department 

255 Christina Street N. PO Box 3018 

Sarnia, ON Canada N7T 7N2 

519-332-0330 (phone) 519-332-8951 (fax) 

healthandsafetyofficer@sarnia.ca
Incident/Claim Information



HH

MM

AM/PM





I.e Please be sure to include specifics in terms of location (i.e nearest intersection, direction travelling) when providing your incident details, as applicable.





Please insert dollar amount only.
Reporter Details
"Reporter" is the person filling out this form


















"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, property manager, employees, etc.)
Involved Person Details




















Select multiple by holding "ctrl".

Select multiple by holding "ctrl".
To add another involved person, please select "Add another response" on the bottom-right portion of this section. This will open another section where information can inserted. If not required, please ignore. 
Involved Vehicle

Note: If you do not know the make of the vehicle, please put "N/A"

If make not known, please insert "N/A"





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

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

This request for information does not constitute an acceptance of your claim but permits the Corporation of the City of Sarnia or its Insurance Representatives to properly record and investigate your claim.


Our employees are instructed to provide this form to you and are not authorized to accept responsibility for claims made. It may be in your best interests to report this matter to your own insurance company.


Please note that claims in which the municipality is not notified within ten (10) days from the time injury or damages were sustained may be statute barred. Also note that legal action which is not brought or commenced within two years from the time injury or damages were sustained may be statute barred.


THE INFORMATION PROVIDED HEREIN IS TRUE, I UNDERSTAND THAT FRAUDULENT CLAIMS COST ALL TAXPAYERS, AND FOR THIS REASON, ALL FRAUDULENT CLAIMS WILL BE PROSECUTED TO THE FULL EXTENT OF THE LAW.


You will be contacted in writing in the near future. Thank you for your co-operation.

Do not admit fault or promise to pay damages. 

If injury occurs or total damage to vehicles exceeds $2,000 Police Services must be contacted. 

Attach police report (if applicable). 

Please contact your Manager and the Health and Safety Officer as soon as possible for further instruction.



NOTE: If you do not agree, the City of Sarnia is unable to accept your on-line form as notice to the City about your claim.

By submitting this form, you confirm that information in this document is correct to your knowledge.