Making a Claim Against the Region

Submit a notice of claim for a loss suffered due to the Region's wrong-doing.

Claims Form

Claimant Information

Claimant's Name

Address

City/Town Prov Postal

Telephone

Cellphone

I prefer to be contacted by: Telephone Cellphone Email

Details of the Claim

Incident Date Time :

Incident Location

Subject of Complaint

Relief Requested

This claim involves vehicle damage due to roadway disrepair

Vehicle Make/Model

Owner of Vehicle

Driver's Name (at the time of the incident)

Passengers (In Vehicle at the time of the incident)

Direction of Vehicle

Speed of Vehicle km/h

Condition of Road

Describe the Weather Conditions at Time of incident

Where is the Exact Location of the Disrepair on the Roadway
(was the disrepair located on the paved portion or shoulder area)

Describe the Disrepair on the Roadway (include dimensions)

Describe any Signs that Warn of Road Disrepair

List Names of any Independent Witnesses

There was Construction in the Area

I have Notified my Auto Insurance Company

Supporting Documentation

I would like to submit electronic documents (photos, reports) supporting my claim

I will send other documentation by mail.

Verify your Submission

Verify your submission by typing the 6-digits you see in the box:

Type in this Number Below
Verify Code * Required

Can't read it? Try a Different Code

Personal information on this form is collected pursuant to the Municipal Freedom of Information and Protection of Privacy Act and will be used for the purpose of processing your claim.

Questions about this collection should be directed to:

Corporate Records Manager, Clerk's Department
2201 St. David's Road, P.O. Box 1042
Thorold, ON L2V 4T7

905-685-1571

Niagara Region

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