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Notice of Claim Form

Name

Address (Street, City, Postal Code)

Email Address

Phone number (Home)

Phone number (Cell)

Date of Incident

Time of Incident

Location of Incident:

Type of Claim

Vehicle Damage

Property Damage

Tree Related

Other

Description of what happened: (Was this area under construction? Weather conditions,if applicable? Was the Police Department notified?

Type of damage or injury that happened.

Estimate as a result of the occurrence.

Attach pictures, estimates, receipts, etc

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Today's Date

Signature

Clear

Freedom of Information

Personal information is collected under the authority of the Municipal Act and Insurance Act of Ontario and is used to process insurance claims. For further information, please contact the Insurance and Risk Management Section, c/o Corporation of City of Cornwall, 100 Water Street, Cornwall, ON, K6H 5T9, 613-930-2787, extension 2332 or email claims@cornwall.ca

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Notice of Claim Form