Claims Against The City

This form has been provided for convenience purposes only. It is not a substitute for preserving your right to bring legal action against the City, for which you will need to also serve a written copy of your claim form on the City Clerk within 10 days of the incident at issue.

Failure to fill out all the required fields and provide all requested and available supporting information and documents may result in the denial of your claim, and such denial will be final with no further recourse against the City.

I Would Like To Submit A Claim For:

1 - Claimant Information

First Name

Last Name

Organization / Business Name

Mailing Address (street number & name, Apt #, Suite #, P.O. Box)

City / Town

Postal Code / ZIP Code

Province / State

Country

Home Phone

Cell Phone

Work Phone

2 - Details of the Claim

Incident Date and Time

Nearest Municipal Street Address (Example: 4310 Queen Street)

Details and Description of Incident

Claim Amount

The claim involves vehicle damage

3 - Vehicle Involved

Vehicle Year

Vehicle Make / Model

Mileage

Owner

Driver's Name

Number of Passengers

Speed

Direction of Vehicle

Lane

Condition of Road

Decribe the weather conditions at time of incident.

Describe the exact location of the disrepair on the roadway (Was the disrepair located on the paved portion or shoulder area?)

Describe the disrepair on the roadway (include dimensions)

Only PDF, JPG, DOC(X), XLS(X), PNG and TXT formats will be accepted.

Photo of Disrepair

Describe any signs that warn of road disrepair (e.g. construction signs, traffic cones, bump ahead)

List names of any independent witnesses

There was construction in the area

I have notified my auto insurance company

Supporting Documentation

Submit electronic documents (photos, estimates, invoices) supporting my claim.

Only PDF, JPG, DOC(X), XLS(X), PNG and TXT formats will be accepted.

Additional Documents

Delivery Options

Via REGISTERED mail, OR
By delivering in person at City Hall between 8:30 a.m. - 4:30 p.m. Monday to Friday, OR
By placing envelope addressed to City Clerk in secure exterior drop box available 24-7. The drop box to be used says “Payments Only No Cash”.
Drop Boxes are found:
- Erie Avenue at City Hall
- Main Entrance at City Hall

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of City staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

NOTE: There may be a delay in receiving confirmation. Please check your junk/spam mailbox to ensure it did not get filtered out. If you have not received the email confirmation by the next business day, please contact Risk Management at 905-356-7521 Ext. 6700.

I confirm I will send this form along with supporting documentation to the City Clerk. The Submitter agrees that checking this box and submitting this form constitutes an electronic signature and the parties may rely upon such electronic signature as though it was an original signature. In addition, the Submitter is certifying that the information submitted is correct.