Type of compensation soughtPlease select the type of compensation being sought:Select type of compensation being sought Property damage Personal injury Motor vehicle Other Select type of compensation being sought Other Contact detailsTitle Mr Ms Mrs Other Name Address Suburb Phone Primary Email * Alternate Email (if applicable) CorrespondenceDo you agree for all correspondence to be sent to you by email? Yes No Provide preferred method of contact Incident details Date of incident Time of incident Location of incident Suburb Closest cross street/s to the incident What occurred Did you contact Council staff at the time of the incident? Yes No Provide name/details of Council officer Compensation sought Please provide details of the type of compensation sought Please also note that the request of this information must not be seen as an automatic acceptance of liability. All claims are assessed based on their own merit and any payments made will come from Council funds. For property/vehicle damage claims, attach any supporting documentation to substantiate your loss. Files must be less than 10 MB.Allowed file types: gif jpg jpeg png pdf doc.Insurance detailsHave you claimed against your insurer? Yes No Claim/policy number Insurance provider Contact name Phone Witness detailsDid anyone witness the incident? Yes No Please attach a witness statement. Note: Council will not contact the nominated witness should a statement not be attached. A decision will be made in the absence of such evidence Files must be less than 10 MB.Allowed file types: gif jpg jpeg png pdf doc docx. Name Phone Email Address Suburb EvidenceTo progress your claim for compensation you will need to establish Council caused the alleged loss and/or damage through some form of negligence. In any public liability claim, the burden of providing proof of negligence rests with the person seeking compensation. Council cannot assist. If your claim is for a tree or pothole related matter, please refer to the tree or pothole evidence page on the website for the required information.Do you wish to attach evidence to this form? Yes No Please explain any evidence you are supplying Attached evidence Files must be less than 10 MB.Allowed file types: gif jpg jpeg png pdf doc docx.PhotosDo you wish to attach photos? Yes No Upload up to 4 photosAttach photo Files must be less than 10 MB.Allowed file types: gif jpg jpeg png.Attach photo Files must be less than 10 MB.Allowed file types: gif jpg jpeg png.Attach photo Files must be less than 10 MB.Allowed file types: gif jpg jpeg png.Attach photo Files must be less than 10 MB.Allowed file types: gif jpg jpeg png.Authority for an agent to actDo you wish for a third party to act on your behalf in this claim? Yes No Name Phone Email Address Suburb Electronic confirmationCouncil will investigate the circumstances surrounding your claim to establish whether or not Council has any legal liability. Completion and acceptance of this form does not represent an admission of liability or a waiver of its rights on the part of Council. Your claim will be subject to investigation and the findings assessed on their own merits. Council will endeavour to respond to claims as quickly as possible. However the processing of claims is dependent on the supply of relevant information and assessment of your claim may take some time to complete.I confirm the information is correct * Confirm Leave this field blank
