Submit a Claim

Name of Claimant(s)

Address of Claimant(s)

Address

Town

Province

Postal Code

E-mail Address of Claimant(s)

Phone Number of Claimant(s)

Nature of Claim

Date of Event or Accident

Time of Event or Accident

Address of Accident

Address

Town

Province

Postal Code

Explanation of accident or event on which claim is based

Amount claimed (please attach supporting documentation below, if possible) $

Supporting Documentation

Unlimited number of files can be uploaded to this field.
64 MB limit.
Allowed types: jpg, jpeg, png, txt, rtf, html, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3.

Reason for alleged Town responsibility

If claim involves property damage, please provide the following insurance information below:

Name of Claimant's Insurance Company

Address of Claimant's Insurance Company

Address

City/Town

Province

Postal Code

Claimant's Insurance Policy Number

Date of Submission

Personal information contained on this form is collected pursuant to the Freedom of Information and Protection of Privacy Act/Municipal Freedom of Information and Protection of Privacy Act and will be used for the purpose of responding to your claim. Questions about this collection should be directed to the Director of Corporate Services/Clerk of the Town of Lincoln.

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