City of Toronto - Claim Submission Form

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City of Toronto - Claim Submission Form

City of Toronto - Claim Submission Form
Instructions:

1. All fields marked with a red Asterisk (*) are mandatory to complete in order to submit the form.

Notice Of Collection:

The City of Toronto's Insurance and Risk Management division collects personal information on this form under the legal authority of the City of Toronto Act, 2006, s. 8, 42(6), 137 and 138; Item No. 6, of Corporate Services Committee Report No. 4, adopted by City Council and confirmed by City of Toronto by means of By-law No. 229-1999 on April 13, 14 and 15, 1999, the City of Toronto Municipal Code, Chapter 169, Officials, City, Article 2, City Clerk, section 169-2.1; Article 3, Deputy City Manager, Corporate Services, Chief Financial Officer and Treasurer and Controller, section 169-3.2, and, Article 5, City Solicitor, sections 169-5.1, and 169-5.3. The information is used to receive; review; investigate; (including contacting and follow up with claimants) as well as determining eligibility with respect to and resolve (including the contesting of the validity of), claims made against the City of Toronto, (including but not limited to written notice of a claim, details of the occurrence, and injury complained of for purposes of s.42 of the City of Toronto Act, 2006). Information will be shared with City Divisions, various agents, consultants, experts and other third parties retained by the City based on the allegations made in the claim, or to undertake work or provide services in relation to the purposes noted above, as the City determines is appropriate. Questions about this collection can be directed to the Supervisor, Claims, Insurance and Risk Management, City Hall, 100 Queen Street West, 5th Floor, East Tower, Toronto, ON M5H 2N2 or by telephone at 416-397-4212.

I am submitting this claim on my behalf

Damage/Injury

There are many ways in which damage or injury may have occurred. For investigation purposes, please select the type of damage or injury from the list

Lawyer/Agent Contact Information

An agent is someone submitting a claim on behalf of the claimant

Involvement Type

Check this box only if you have a Single Name on your Registered Birth Certificate or Change of Name Certificate (rather than a First Name and Last Name).

First Name

Last Name/Business Name

Single Name

A Single Name is a naming practice in some Indigenous and other cultural traditions. It does not consist of a First Name and a Last Name.

Birthdate

Gender

Home Phone

Phone

Mobile Phone

Business Fax

Title

Adjuster Number

Badge Number

Contact Description

Street

City

Province/State

Country

Postal Code/Zip

Sustained Injury?

Seek Medical Attention?

Care from Emergency Medical Services?

Description of Personal Injuries

Call Phone Number from Ambulance Call Report

Have you received any other medical aid?

Health care provider's name

Part of Body

Select multiple by holding "ctrl".

Nature of Injury

Select multiple by holding "ctrl".

Claimant Claim Number

Employee Doing Regular Job?

Lost Time?

Required Hospital Time

Last Worked Date

Treated in an Emergency Room?

Hospitalized Overnight as an In-Patient?

First Disability Date

Return to Work Date

First Full Workday Lost After Injury

Return to Work Restricted?

Hospital Name

Hospital Street Address

Hospital City

Hospital State/Province

Hospital Zip/Postal Code

NCCI Class Code

NCCI Injury Code

NCCI Loss CovCode

NCCI Type Code

Lost Days

Restricted Days

Time Workday Began

A/P

AM/PM

OSHA Record?

OSHA Classification

OSHA Injury Type

OSHA Accident Location

OSHA Injury Description

Claimant Contact Information

A claimant is the person or business who suffered the damage or injury

Check this box only if you have a Single Name on your Registered Birth Certificate or Change of Name Certificate (rather than a First Name and Last Name).

Involvement Type

First Name

Last Name/Business Name

Single Name

A Single Name is a naming practice in some Indigenous and other cultural traditions. It does not consist of a First Name and a Last Name.

Gender

Birthdate

Home Phone

Phone

Mobile Phone

Business Fax

Adjuster Number

Badge Number

Title

Contact Description

Street

City

Province/State

Country

Postal Code/Zip

Did this person sustain an Injury?

Seek Medical Attention?

Care from Emergency Medical Services?

Description of Personal Injuries

Call Phone Number from Ambulance Call Report

Have you received any other medical aid?

Health care provider's name

Part of Body

Select multiple by holding "ctrl".

Nature of Injury

Select multiple by holding "ctrl".

Claimant Claim Number

Claimant Insurance Company

Employee Doing Regular Job?

Lost Time?

Required Hospital Time

Last Worked Date

Treated in an Emergency Room?

Hospitalized Overnight as an In-Patient?

First Disability Date

Return to Work Date

First Full Workday Lost After Injury

Return to Work Restricted?

Hospital Name

Hospital Street Address

Hospital City

Hospital State/Province

Hospital Zip/Postal Code

NCCI Class Code

NCCI Injury Code

NCCI Loss CovCode

NCCI Type Code

Lost Days

Restricted Days

Time Workday Began

A/P

AM/PM

OSHA Record?

OSHA Classification

OSHA Injury Type

OSHA Accident Location

OSHA Injury Description

Incident/Claim Information

City of Toronto does not maintain 400-series highways (400, 401, 403, 404, 409, 427) and Queen Elizabeth Way (QEW), please contact Ministry of Transportation of Ontario.

Date of Loss

Format Example: 12/31/2000

Did your incident occur on a highway?

Lane of Travel

Nearest off/on Ramp

Direction of Travel

Incident Address

Incident Country

Incident City

Incident Province/State

Incident Postal Code/Zip

Incident Description

Please provide a brief description of the damage or injury that occurred. This claim will be submitted to the City's Third Party Adjuster who will contact you within two business days. At that time, you will be able to submit any picture and claim related documentation to your adjuster.

Incident Cost Incurred

Cause

Source

Litigation?

Record Type ID

Owned/Leased Vehicle Involved?

Owned/Leased Property Involved?

3rd Party Vehicle Involved?

3rd Party Property Involved?

Department

Did you notify 311?

311 Service Request Number

Litigation Details

Legal Representation

Statement of Claim

Statement of Claim Number

State/Province of Jurisdiction

Legal Disclosure Date

Legal Representation Date

Plaintiff Attorney Disclosure Date

Plaintiff Attorney Representation Date

In Suit?

Suit/Case Name

Suit Filed Date

Follow-Up and Corrective Actions

What was the person doing?

Follow Up Completed By:

How can a similar occurrence be prevented?

Need Assistance from safety partner?:

Lessons learned to prevent injuries:

Action Taken:

Safety Partner Assigned

Additional Notes

Areas for Corrective Action

Sub Area

Priority

Involved Vehicle (Internal)

Vehicle VIN

Description of Damages to Vehicle

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

Involved Properties (Internal)

Property Name

Description of Damages to Property

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

3rd Party Involved Vehicle

Vehicle Type

3rd Party Vehicle Colour

3rd Party Vehicle Make

3rd Party Vehicle Model

3rd Party Vehicle Year

3rd Party Vehicle License Plate Number

3rd Party Vehicle VIN

Description of Damages

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

3rd Party Involved Property

3rd Party Property Address

3rd Party Property City

3rd Party Property State/Province

3rd Party Property Country

3rd Party Property Zip/Postal Code

Description of Damages

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