City of Welland Claim/Incident Reporting Form

Reporter Details

"Reporter" is the person filling out this form

Involvement Type

First Name

Last Name

Phone

Mobile Phone

Badge Number

Mailing Street	Mailing City
Mailing State/Province	Mailing Country
Mailing Zip/Postal Code

Did this person sustain an Injury?

Description of Personal Injuries

Claimant Claim Number

Claimant Insurance Company

Incident/Claim Information

Incident Date/Time

A/P

AM/PM

Incident Address	Incident City
Incident State/Province	Incident Country

Incident Description

3rd Party Vehicle Involved?

Construction in Area?

An 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, police officer, employees, etc.)

Do you wish to add Involved Persons to this report?

Construction Information

Location of Construction

Type of Construction

Name of Construction Company (if known)

Do you recall if there were any construction signs, traffic cones, etc.?

Involved Person Details

Involvement Type

First Name

Last Name

Phone

Mobile Phone

Adjuster Number

Badge Number

Mailing Street	Mailing City
Mailing State/Province	Mailing Country
Mailing Zip/Postal Code

Sustained Injury?

Description of Personal Injuries

Claimant Claim Number

Claimant Insurance Company

Lost Time?

To add another Involved Person, please select "Add Another Involved Person" on the bottom-right 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 Vehicle" on the bottom-right portion of this section.

Attachments

Please upload any supporting documents, images, invoices, or estimate of damages.

(Note: There is a 25 MB per file size limit, a 35 MB total file size limit, and a 10 file limit per submission.)

Do you wish to add Files/Attachments?

To add more than one file, select "Add Another File/Attachment". To remove a file, select "Remove".

File Upload

Declaration

The information provided herein is true. I understand that submitting false statements and/or

documentation is a form of fraud and is illegal. I acknowledge that fraudulent claims cost taxpayers, and that claims that are determined to be made fraudulently will be prosecuted to the full extent of the law.

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

I accept that the City will disclose my personal information to the City’s insurance adjuster and/or to those involved in the resulting claim resolution, including but not limited to lawyers, or third parties that are found responsible for losses claimed.

I have read, acknowledge and understand the consequences and agree with the statement above

I agree

NOTE: If you do not agree, the City of Welland is unable to accept your on-line form as notice to the City about your claim.