Damage Claim Form

Our employees are instructed to provide this form to you and are not authorized to accept responsibility for claims made.
Claimant's Name*
First Last
Claimant's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Phone (Alternate)
Email
Date of Incident*
MM slash DD slash YYYY
Time of Incident*

: Hours

Minutes

AM/PM
Location of Incident*
Details of Incident (Please provide SPECIFIC information regarding the incident and type of damage)*
If you are seeking compensation, please specify dollar amount.
If your are seeking compensation, please attach copies of estimates, receipts, photos etc.
Drop files here or

Max. file size: 98 MB.
Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif
This request for information does not constitute an acceptance of your claim but permits the Corporation of the City of Quinte West or its Insurance Representative to properly record and investigate your claim.
Signature of Claimant is Required. Please acknowledge that you are the person who is named in this claim and that all information is accurate to the best of your knowledge.*
Date Damage Form was Submitted by Claimant*
MM slash DD slash YYYY
Personal informaton on this form is collected under the authority of the Municipal Act and Insurance Act of Ontario and is used to process claims made against the municipality. For further information please contact insurance@quintewest.ca

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