Claim for Compensation

Claim for Compensation Form

By submitting these details you are creating a claim against Haldimand County.

What Type of Claim are you submitting?*
Name of Insurance Company*
Contact for Insurance Company*
First Last
Insureds Name*
First Last
Claimant's Name*
First Last
Claimant's Address*
Street Address Address Line 2 City Province Postal Code
Contacts Email*
Claimant's Email*
Contacts Phone Number*
Claimant's Phone Number
Date of Incident*
YYYY dot MM dot DD
Time
: Hours
Minutes
AM/PM
Name of Contractor if known*
Incident Location*
Description of Incident*
Was the OPP contacted?*
Police report number if known*
Was medical assistance required?*
Who provided medical assistance?*
- County Staff
- Emergency Services (Ambulance or Fire)
- Medical Assistance after the Incident (Hospital)
- Other
Please click all that apply
Describe other*
State why you feel the County is responsible for your damage or injury and what you would like the County to do.*
Estimates or Receipts
Drop files here or
Max. file size: 512 MB.
Please upload estimates or receipts here.
Photos
Drop files here or
Max. file size: 5 MB.
Please Attach any photos here
Consent*
Acknowledgement of Fraudulent Claims
Any person who, with intent to defraud or knowing that they are facilitating a fraud against an insurer, submits an application or files a claim containing false information, is guilty of insurance fraud.
Consent*
I agree to the privacy policy.
Personal information on this form is collected under the authority of the Municipal Act, 2001 and the Municipal Freedom of Information and Protection of Privacy Act and will be used to process your claim, including the possible disclosure to third parties to verify and investigate this claim. Questions regarding this collection or disclosure of this record can be sent to the FOI Coordinator at 905.318.5932 x 6362.
Signature*
Date*
YYYY dot MM dot DD

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Claim for Compensation

Claim for Compensation Form

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