Norfolk Public Incident/Claim Form

Note: All fields with a red asterisk (*) and include "(Required)" must be completed in order to submit the form.

Personal information on this form is collected under the authority of the Municipal Act 2001, C.25 and will be used to investigate and manage your claim. This information may be shared, as necessary, with insurers, legal counsel, or contractors involved, as permitted by Ontario privacy law.

NOTE: Notice of an injury claim must be submitted to the municipality within ten (10) days of the occurrence as per Section 44(10) of the Municipal Act 2001. A two (2) year limitation period to submit a legal action will apply as per Section 4 of the Limitations Act, 2002 S.O. 2002, Chapter 24, Schedule B

NOTE: Incident Date must be entered in the following format: MM/DD/YYYY in the text box above. For example, August 24, 2021 should be input as 08/24/2021. A calendar will also appear if the text box is clicked on.

NOTE: When inserting Incident Description, please be as descriptive as possible and include details about the incident such as property/vehicle damage, intersection details, construction and/or weather details, etc.

NOTE: Retain all written proof (i.e. invoices) of the “Costs Incurred”, as these will be required. Leave blank if you do not have an estimate at this time.

"Claimant" 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.)

To add more individuals to this report, such as another witness or person affected, please select "Add Another Involved Person" below. This will open another section where information can be inserted. If not required, please ignore. If you selected to add another involved person and no longer require it, please select "Remove" on the new involved person details section.

Note: There is a 25 MB per file size limit and a 35 MB total file size limit per submission.

Please upload any supporting documents, images, invoices, or estimate of damages. Should you have more than 10 attachments to submit or encounter difficulties uploading a file, please note that you can email these files directly to the examiner assigned once your claim is setup.

To add more files to this report, please select "Add Another File Upload" below. This will open another section where information can be inserted. If not required, please ignore. If you selected to add another file upload and no longer require it, please select "Remove" on the new file upload section.

The Municipality designated at the top of this form is participating in a program conducted by Local Authority Services (LAS) that provides the digital platform for this form. LAS receives aggregate data in compliance with the Municipal Freedom of Information and Protection of Privacy Act, on insurance claims for the purpose of improving the digital platform and the LAS municipal risk management program.