Town of Milton Incident Form
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Claimant Information
First Name
Last Name
Mailing Address
Town
Province
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Postal Code
Primary Phone
Secondary Phone
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Is the Contact Information different than the Claimant Information?
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Contact Information
First Name
Last Name
Mailing Address
Town
Province
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BC
MB
NB
NL
NS
NT
NU
ON
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QC
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YT
Postal Code
Primary Phone
Secondary Phone
Email
Relationship to Claimant
Incident Information
Date of Incident
Incident Time
FORMAT: ##:## (AM/PM) - EXAMPLE: 05:38 PM
Town/City of Incident
Address or approximate location of incident
Description of Incident
Please provide specific information regarding the incident which occurred.
Additional Details
Please provide any additional information about the incident.
Damages Claimed
If you are claiming damages, identify what damages have you incurred. You will be required to prove your damages.
Additional Details
Witness Detail
This claim involves a vehicle
There was property damage
Bodily Injury was sustained
There was construction in the area
Your insurance provider has been notified
A police report was filled
Weather
Clear
Rain
Snow
Fog
Freezing Rain
Hail
Light
Daylight
Dawn
Dusk
Dark
Road Surface
Paved
Unpaved
Off-road
Witness Details
Witness #1 Details
Witness #1 First Name
Witness #1 Last Name
Witness #1 Phone
Witness #1 Email
Add Second Witness
Witness #2 Details
Witness #2 First Name
Witness #2 Last Name
Witness #2 Phone
Witness #2 Email
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.
Occurrence Report Number
From Motor Vehicle Collision Report
Police Agency
Officer's First Name
Officer's Last Name
Badge Number
Vehicle Incident Information
Vehicle License Plate Number
Vehicle Year
Vehicle Model
Vehicle Colour
Vehicle VIN Number
Vehicle Owner, if different than claimant
Property Damage Information
Description of Property Damage
Insurance Provider Information
Insurance Company
Claim Number
Insurance Representative Name
Insurance Representative Email
Insurance Representative Phone Number
Bodily Injury Information
Please provide specific information regarding the bodily injury you received as a result of the incident
Did you receive care from Emergency Medical Services personnel (I.E., was an ambulance called)?
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Yes
What emergency medical services did you receive?
Description of Bodily Injuries
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
Construction Company, if known
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.
Do you have any files to upload? (Required)
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Attachments
File Upload
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
.
Signature
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