Claim for Compensation Form Uralla Shire Council

How to complete this Claim for Compensation form

Only complete this form if you are the person claiming personal injury, property damage, or you are the owner of the motor vehicle.

Please Note: The request of this information is not acceptance of liability. All claims are assessed on their own merit.

1. Contact Details

Preferred Title:

First Name:

Last Name:

Address:

Email:

Telephone:

2. Type of compensation sought

Property
Personal injury
Motor vehicle
Other

If other, please specify:

Date and time of alleged accident/incident:

Incident date:Incident date:

Open the calendar popup.

Incident time:

Location of alleged accident/incident:

To assist us in identifying the exact location, please provide details of the nearest cross streets and/or any identifying landmarks where the alleged accident/incident occurred.

Incident location:

Details of the alleged accident/incident:

Details of what you are claiming:

3. Insurance Details

Claim/Policy number:

Insurance provider:

Insurer contact name:

Insurer contact number:

4. Witness

It is the responsibility of the claimant to obtain the witness statement and submit with your claim. If a witness statement has not been attached to your claim, a decision will be made in the absence of this evidence.

Witness contact name:

Witness contact number:

Witness email:

Witness address:

Attach witness statement:

5. Evidence and supporting documentation

You are required to establish that we caused the alleged loss and/or damage through some form of negligence. In any public liability claim, the burden of providing proof of negligence rests with you as the person seeking compensation. We cannot assist you in this.

Evidence and supporting documentation are required to evaluate your claim. If this information is not provided it may delay your application.

Evidence - such as a report from a qualified service provider, a medical practitioner, a mechanic

Supporting documentation – such as quotations, out of pocket expenses

6. Photographs

One of the most effective ways to avoid confusion about the circumstances surrounding your claim is through the use of photographs. Only take photographs if it is safe to do so. You are requested to provide a variety of shots and angles to clearly show the situation which supports your claim. Your photographs need to show the following (where applicable):

Vehicle damage examples include the area that has sustained damage (eg car door, windscreen), or a photograph clearly showing the side where the damage occurred (eg passenger/driver’s side)

Personal injury examples include a clearly marked area where the accident/incident occurred, or a photograph clearly showing the surrounding area in relation to the alleged hazard

Property damage examples include a clearly marked area where the accident/incident occurred, or a photograph clearly showing the surrounding area in relation to the alleged hazard

Attach photographs:

7. Declaration and Acknowledgement

In submitting this form, I declare that the information supplied to the Uralla Shire Council in this claim form is true and correct and confirm the statements are honestly made.

Completion and acceptance of this form does not represent an admission of liability on the part of Uralla Shire Council and/or our insurers. Your claim for compensation will be subject to investigation and will be assessed on its own merits.

Claim for Compensation Form