Required fields are marked with asterisks (*)

Personal Information of Claimant

First Name

Last Name

Mailing Address

Phone

Alternate Phone

Email Address

Vehicle Make and Model

Vehicle Year

Vehicle Kilometres

Are you the vehicle owner?

Yes

If no, please provide the name and phone number of the vehicle owner

Incident Information

Date of Loss

Time of Loss

Exact Location of Loss

Closest Intersection/Landmark

Describe Weather Conditions at Incident

Detailed Description of Incident (including direction travelled, injuries and property damage. If pothole issue, please include length, width and depth):

Have you notified your Insurance Company?

Yes

Enclosures (check all that apply):

Photo(s)

Receipt(s) or 2 Estimates

Other

Please attach enclosure(s). Maximum file upload size is 10 MB. Additional files can be emailed to pjudson@bracebridge.ca:

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Allowed extensions pdf, doc, docx, jpg, jpeg, gif, png, tif

I consent to the disclosure of my personal information and all other information provided on this form to any third-party that the Town of Bracebridge determines may hold responsibility for your claim

Yes

NOTICE OF COLLECTION

This form is provided without prejudice and without admitting any legal liability on the part of the municipality.

The personal information you choose to provide on this form is collected pursuant to the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA), M.56 R.S.O. 1990. The information you provide will be used to investigate the complaint and may be used for contact purposes. Questions about this collection can be directed to Director of Corporate Services/Clerk.

Forms

Personal Information of Claimant

Incident Information

NOTICE OF COLLECTION

Submit A Claim