Statement of Damage Claim Form

Claim form

For completion by a party claiming the municipality is at fault for damages to their property.

"*" indicates required fields

Claimant Information

For more information on submitting your claim please visit our Risk Management page. sturgeoncounty.ca/risk-management/

First Name*

Last Name*

Address*

City*

Province*

Postal Code*

Phone*

Incident Information

Incident Date*

Approximate Time of Incident

AM/PM

Location of Incident

Description of Damage

Include year/make/model/mileage of auto and date of last repair/replace.

Description of Incident

Please indicate the cause of damage.

Amount of claim

Include how you calculated, and upload any supporting documents below.

Did anyone in the vehicle sustain any bodily injuries?

Yes

Please describe the injuries

Supporting Document Upload

Drop files here or

Max. file size: 512 MB.

Please upload any supporting documents you have, including Repair Estimates, Photographs, Receipts, and if applicable a map/diagram of the incident.

When was the damage first reported to the Municipality and to who?

Be specific with dates/times, names, phone# called, and any ticket or reference numbers provided to you.

Witness Info

Witness 1 Name

Witness 1 Relationship

Witness 1 Address

Witness 1 Phone

Witness 2 Name

Witness 2 Relationship

Witness 2 Address

Witness 2 Phone

Witness 3 Name

Witness 3 Relationship

Witness 3 Address

Witness 3 Phone

Acknowledgement*

I solemnly swear that I am the owner/occupier of the property damaged, that the foregoing is a correct and accurate statement as to the damages incurred and that I have no insurance or warranty of any type under which such damages may be recoverable.

Date*

Please note: This statement is for information purposes only and its receipt in no way infers acceptance of any responsibility by this Municipality for the stated damages. A fully completed and signed form is to be send to the County address above by mail, e-mail or fax upon which you should receive a written confirmation acknowledging your claim receipt within 30 days time. Be aware that there are notice periods for providing the County with notice of certain types of claims and limitation periods with respect to all claims. If you do not commence legal action to advance your claim within two years of the date of the incident cause loss or damage Sturgeon County and its employees will be entitled to immunity from liability in respect of your claim pursuant to the provisions of the Limitations Act of Alberta.

This personal information is collected un the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act and will be used to process claims against the County. It may also be disclosed to third parties to verify the information given.

It is protected by the privacy provisions of the Act. If you have any questions about the collection, use or disclosure, contact the Risk Management and Insurance Coordinator at 780-939-1393.