Fillable Statement Of Damage/injury Form printable pdf download

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CORPORATE SERVICES DEPARTMENT

Risk Management Section

10th Floor Chancery Hall

3 Sir Winston Churchill Square

Edmonton, Alberta T5J 2C3

Phone: 780-496-5130

Fax: 780-496-5149

Email: riskmanagement@edmonton.ca

File #:

STATEMENT OF DAMAGE/INJURY FORM

For completion by a party claiming the Municipality is responsible for damages to their property or person.

1. CLAIMANT INFORMATION

MR/MRS/MISS:____________________

First Name:_____________________________

Last Name:_____________________________

Address:____________________________________________________________________

City:___________________________________

Province:____________ Postal Code:_________

Daytime Phone:__________________ E-Mail:__________________________________

2. DESCRIPTION OF DAMAGED PROPERTY/INJURY: (include year/make/model/mileage for auto damage claims and date of last repair/replace)

3. INCIDENT DATE AND TIME:

MM/DD/YYYY

Time (24:00)

4. LOCATION OF INCIDENT:

(Please be specific referencing direction of travel, lane and closest intersection or reference point and enclose diagram or map if needed)

5. AMOUNT OF CLAIM: (include how calculated and supporting documentation such as photos and estimates or receipts)

_______________________________________________________________________________________________________________________

6. INDICATE CAUSE OF DAMAGE OR INJURY:

_______________________________________________________________________________________________________________________

7. WHEN WAS THE DAMAGE/INJURY FIRST REPORTED TO THE MUNICIPALITY AND TO WHO?

(Please be specific with dates/times, names, phone# called, and any ticket or file reference numbers that were provided)

8. NAMES, ADDRESSES AND TELEPHONE NUMBERS OF ALL WITNESSES AND MUNICIPAL STAFF INVOLVED:

Name/Relationship

Address

Telephone Number

9. FOR CLAIMS INVOLVING CITY BUSES OR VEHICLES:

ETS Edmonton Transit File#

Fleet File#

Bus or City Vehicle# (or license Plate)

Police File#

10. STATE WHY YOU FEEL THE MUNICIPALITY SHOULD BE RESPONSIBLE FOR YOUR DAMAGE/INJURY AND WHAT YOU WOULD LIKE THE

CITY TO DO:

11. 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.

Owner:

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 sent to the City address above by mail, e-mail or fax upon which you should

receive a written confirmation acknowledging your claim receipt within two weeks time. Be aware that there are notice periods for providing

the city with notice of certain types of claims and limitation periods in respect of all claims. If you do not commence legal action to advance

your claim within two years of the date of the incident causing your loss or damage, the City of Edmonton 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.

Statement Of Damage/injury Form

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