Claims Assessment Form

The provisions of this claim form is not an admission of liability on Council's part
The information will be used to investigate and assess your claim
All questions must be fully answered in clear print or typed, where applicable
The form must be signed by the property owner/ claimant
Please contact Canterbury-Bankstown Council if you need assistance with completing this form on 9707 9000.

Type of Claim *

Are you the claimant? *

YesNo

If "Other" Please supply further details

Contact details

Relationship to claimant *

Surname>

Given Name(s)>

Postal Address

Post Code>

Contact Number

Email Address >

Last name *

Given Name (s) *

Residential address *

Daytime Contact Number *

Email Address *

Incident details

Incident Street Number *

Incident Street Name *

Incident Suburb *

Post code number

Time of Incident *

Date of Incident *

Description of the Incident *

Who/what do you think caused the incident *

Why do you think Council is responsible for the incident? *

Are there any witnesses to the incident? *

Yes (if yes please complete witness details below) NoNot Applicable

Witness details

Witness Name *

Witness Contact Number *

Witness 2 Name

Witness 2 Contact Details

Witness 3 Name

Witness 3 Contact Details

Personal Injury details

Did the incident result in injury? *

YesNo

What is your injury/condition? *

Which parts of your body are affected? *

What task/s were you doing when you were injured? *

Medical treatment details *

Did you attend hospital? *

YesNo

Name of the hospital

Property Damage Detail

Did the incident result in property damage? *

YesNo

Detail the items/ type of damage *

Has the issue been reported to Council *

Date Reported *

Incident report number

Details of what was reported *

Sewer Damage Details

Has the issue previously been reported to Council *

Date Reported. *

Incident Report Number.

Details of what was reported *

Have you engaged a plumber to attend the site *

YesNo

If Yes please attach plumbers report and photos as part of the evidence below

Motor Vehicle Damage Details

Was a Council vehicle involved in the incident? *

YesNo

What was the number plate of the Council Vehicle *

Did the incident result in damage? *

Yesno

Description of Damage *

Are you the owner of the vehicle? *

YesNo

If no, please provide details of the registered owner

Number of years licensed

Description of incident *

Details of damage (please mark on vehicle below using your mouse) *

Clear drawing

Vehicle year *

Vehicle Make/Model

Registration Number *

Have you lodged a claim with your insurer? *

YesNo

Please illustrate the incident details. Include street names and intersections. Show the point of impact, the position of your vehicle and of any other vehicle involved in the incident.

Proceed to upload your diagram as an attachment

Diagram attachment

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Please outline any further information to be considered

Attachment(s)

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Evidence Checklist

The Claims assessment form must be completed with associated supporting documents and evidence for a claim to be assessed. Please tick which evidence you will be supplying and ensure you upload the documents to this form.

Please upload all relevant evidence documents

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Declaration

I declare that I am over 18 years of age and the above particulars are true in every respect, and no information is being withheld or misrepresented.

Under section 307C of the Crimes Act 1900, you can be penalised up to $22,000 or imprisoned for two years, or both, for knowingly providing false or misleading information in this form.

The above information is, to the best of my knowledge and belief, true in every respect and no information is being withheld or misrepresented.

Date of submission *

Signature of person completing this form *

Draw signature|Type signatureClear

Date signed *

All parts of the form have been completed *

Copes of relevant information attached: *

Privacy policy

In submitting this form, you consent to Council:

1. collecting your personal information as contained in the form; and

2. using the information for the purposes outlined in the form.

Providing your information is voluntary. Should you choose not to provide the information, Council is unable to process your application/request.

Under the Government Information (Public Access) Act 2009 (GIPA Act), you have the right to request access to various types of records held by Council, including your personal information. Council’s website contains information regarding how to make a formal request under the GIPA Act for information held by the council https://www.cbcity.nsw.gov.au/onlineservices/gipa-formal-access-to-information-application-form It's important to note that some records may be exempt from disclosure due to specific provisions in the GIPA Act. Fees may be payable.

Accept Privacy Policy *