Police Agency: (Ex.: SSM Police Service, OPP, etc.)

Transcription

1 CLAIM NO. MOTOR VEHICLE DAMAGE CLAIM (PLEASE PRINT) Your claim cannot be considered by the City until this form is fully completed. Once completed, please submit this form to the City Clerk s Department, located on the 4 th floor of the Civic Centre at 99 Foster Drive. Upon receipt of your claim, you will receive an ac knowledgement letter to the address provided outlining how this process will proceed. PERSONAL INFORMATION OF CLAIMANT CONTACT INFORMATION (if different from Claimant s) Relationship to Claimant INCIDENT DETAILS Date of incident: (mm/dd/yy) _ Address or approximate location of incident: _ Did you sustain a personal injury? Yes No (If Yes, please complete Schedule A attached to this form). Time of incident: AM PM Type of claim: Pothole Collision with a City vehicle Other: Has your insurance provider been notified of the incident? Yes No POLICE REPORT (if applicable) Collision Number: (from Motor Vehicle Collision Report) Officer s Name: Police Agency: (Ex.: SSM Police Service, OPP, etc.) Badge Number: 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, must report the accident to the nearest police officer forthwith. Page 1 of 6

2 WITNESS INFORMATION 1 (if applicable) WITNESS INFORMATION 2 (if applicable) DESCRIPTION OF INCIDENT Please provide specific information regarding the events surrounding your claim. Page 2 of 6

3 TRAFFIC DIAGRAM Please select the portion of the diagram that most accurately depicts the roadway where the incident (i.e., damage) occurred. ENVIRONMENTAL CONDITIONS Please select all that apply. Weather: Clear Rain Snow Fog Freezing Rain Hail Light: Daylight Dawn Dusk Dark Road: Paved Unpaved Off-road Other: Page 3 of 6

4 DIAGRAM OF DAMAGE TO VEHICLE Please indicate the approximate location of the damage to your vehicle with an X. Licence plate number: Vehicle model & year: Vehicle colour: Vin number: DESCRIPTION OF PROPERTY DAMAGE Please provide specific information regarding the damage sustained to your personal property. COSTS INCURRED What costs, if any, have you incurred as a result of this incident? Please provide supporting documentation. Page 4 of 6

5 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 f orwarded to the City s Legal Department for further consideration. Photos of damage Quotes/Estimates Receipts Police Report/Motor Vehicle Collision Report Schedule A Personal Injury Report Medical/Doctor s Report(s) Other: 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. If you have any knowledge that the alleged damages might have occurred as a r esult of work being performed by a contractor on behalf of The Corporation of the City of Sault Ste. Marie (the City ) or a public utility, please report this information to the City Clerk s Department immediately ( ). The personal information contained on this form shall be us ed solely for the purpose of processing the damage and/or personal injury claim and will be supplied to the City s insurance adjuster and/or to those from whom the City is claiming contribution or indemnity. Questions about this collection of information can be made to the City s Legal Department ( ). Signature of Claimant: Date: UPON COMPLETING THIS FORM, PLEASE SUBMIT IT AND ALL ATTACHMENTS TO: City Clerk s Department Civic Centre Level 4 99 Foster Drive Sault Ste. Marie, ON P6A 5X6 Fax: FOR OFFICE USE ONLY City Clerk s Department City Legal Department Form complete: Yes No Date returned to claimant (if applicable): Distribute: PWT Transit HR CSD ENG Other: Page 5 of 6

6 SCHEDULE A PERSONAL INJURY REPORT PERSONAL INFORMATION (if different from Claimant on Motor Vehicle Damage Claim form) What was your role in the incident outlined in the Motor Vehicle Damage Claim form (I.e., driver, passenger, etc.)? DESCRIPTION OF PERSONAL INJURIES Please provide specific information regarding the injuries you sustained. DESCRIPTION OF MEDICAL AID (if applicable) Please provide specific information regarding the medical aid you received and/or are receiving as a result of the incident. Did you receive care from Emergency Medical Services personnel (I.e., was an ambulance called)? Yes No Call Number from Ambulance Call Report: Have you received any other medical aid? Yes No Health care provider s name: Page 6 of 6 Mar. 16/17