Burlington Claim Submission

Purpose If you have suffered a loss for which you believe the City may be responsible, you can file a claim against the City using this form. In situations involving disrepair of a City road or sidewalk, you will be required to provide notice to the City within 10 days of the incident.

If you have any questions regarding this form, please contact the Insurance & Risk Management Officer at 905-335-7600 X 7582 or claimsadministrator@burlington.ca.

Notice of Collection Personal information contained on this form is collected under the authority of the Municipal Act, 2001, S.O. 2001, c. 25 and will be used for the purposes of receiving, assessing, and responding to claims submitted to the City. Questions about this collection should be directed to:

Insurance & Risk Management Officer

426 Brant Street

P.O. Box 5013

Burlington, ON L7R 3Z6

T: 905-335-7600 ext. 7582

E: city@burlington.ca

Collection Consent Does the City of Burlington have your consent to collect, use or disclose your information that is necessary and reasonable for the purposes of processing your claim?

NOTE: If you select 'No', the City of Burlington is unable to accept your on-line form as notice to the City about your claim.

I hereby give consent to the City of Burlington to collect, use or disclose my information that is necessary and reasonable for the purposes of processing my claim:

Claimant Information

First Name	Last Name
Street #	Street Name
Unit #	Ward
City	Province
Postal Code	Email Address If you enter your email address, you will receive a copy of this form after submission
Daytime Primary Phone	Daytime Primary Phone Extension
Daytime Secondary Phone	Daytime Secondary Phone Extension
I prefer to be contacted by

Incident Details

Incident Date and Time

AM/PM

Incident Address

Incident City

Incident Province

Incident Description

Additional Details

This claim involves vehicle damage due to road conditionsThere was construction in the areaYou have notified your insurance company

Vehicle Damage Due To Road Conditions

Vehicle Make

Vehicle Model

Owner of Vehicle

Driver First Name

Driver Last Name

Passengers (in vehicle at time of incident)

Direction of Vehicle

Speed of Vehicle (km/h)

Road Surface Conditions

Environment Conditions

Where was the exact location of the disrepair on the roadway?

Describe the disrepair on the roadway

Describe any signs of warning of road disrepair

Were there any Independent Witnesses?

Witness Information

First Name	Last Name
Phone Number	Email
Street Address	City
Province	Postal Code

If there are additional witnesses beyond this one, please click "Add Another Witness" to the bottom right of this text. Should you accidentally add another response and wish to remove it, click on the "Remove" option that will be available at the bottom of that section.

Construction In The Area

Construction Company

I Have Notified My Insurance Company

Insurance Company

Claim Number

Adjuster Name (assigned to your claim)

Attachments

Please submit copies of all documents supporting your claim including photos, estimates, invoices, etc. You may submit your supporting documents by mail (using the address below) or electronically (using the buttons below).

By Mail:

Claim Submission, c/o City Clerk

426 Brant Street, P.O. Box 5013

Burlington, Ontario L7R 3Z6

File 1

File 2

File 3

File 4

Contact Information