Milton

Town of Milton Incident Form

NOTE: If you select 'No', the Town of Milton is unable to accept your online form as notice to the Town about your claim.
Claimant Information










Contact Information










Incident Information


FORMAT: ##:## (AM/PM) - EXAMPLE: 05:38 PM



Please provide specific information regarding the incident which occurred.

Please provide any additional information about the incident.


If you are claiming damages, identify what damages have you incurred. You will be required to prove your damages.



Witness Details
Witness #1 Details




Witness #2 Details




Police Report
Note: Pursuant to s. 199 (1) of the Highway Traffic Act, R.S.O 1990, c. H. 8, individuals who are involved, either directly or indirectly, in a vehicle-related accident that results in personal injuries or property damage in excess of $2,000.00 must be reported the accident to the police forthwith.

From Motor Vehicle Collision Report




Vehicle Incident Information






Property Damage Information

Insurance Provider Information





Bodily Injury Information
Please provide specific information regarding the bodily injury you received as a result of the incident



Please provide specific information regarding the injuries you sustained including the part of the body injured and the nature of the injury.
There was Construction in the Area

Attachments
Please include copies of all documentation you currently have related to this incident so that your claim can be considered. Additional documentation subsequent to submitting this form should be forwarded to the Town’s Purchasing & Risk Management Division.
To add more files, please select "Add Additional Attachment" below. This will open another section where information can be inserted. If you selected to add additional attachment and no longer require it, please select "Remove" on the new file upload section.

Attachments

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud, or submits an application or files a claim containing a false or deceptive statement, is guilty of fraud.
The personal information contained on this form shall be used solely for the purpose of processing the damage and/or bodily injury claim and may be supplied to the Town’s insurance adjuster and/or to those from whom the Town is claiming contribution or indemnity. Questions about this collection of information can be made to the Town’s Purchasing & Risk Management Division (905-878-7252) or Risk Services.