Share This is the online claim submission form only. You must have JavaScript enabled to use this form. Type of compensation sought Property damage Personal injury Motor vehicle Other… Enter other… Contact details Contact details Title Mr Ms Mrs Other… Enter other… Name Address Suburb Phone Primary email Alternate email (if applicable) Provide preferred method of contact Correspondence Do you agree for all correspondence to be sent to you by email? Yes No Incident details Date and time of incident Date and time of incident: Date Date and time of incident: Time Location of incident Suburb Closest cross street/s to the incident What occured Did you contact Council staff at the time of the incident? Yes No Provide name/details of Council officer Compensation sought Please provide details of the type of compensation sought For property/vehicle damage claims, attach any supporting documentation to substantiate your loss. One file only.10 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Insurance details Have you claimed against your insurer? Yes No Claim/policy number Insurance provider Contact name Phone number Witness details Did anyone witness the incident? Yes No Please attach a witness statement. Note: Council will not contact the nominated witness should a statement not be attached. A decision will be made in the absence of such evidence One file only.10 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Witness details Name Email Phone Address City/Town Evidence Do you wish to attach evidence to this form? To progress your claim for compensation you will need to establish Council 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 the person seeking compensation. Council cannot assist. If your claim is for a tree or pothole related matter, please refer to the tree or pothole evidence page on the website for the required information. Yes No Please attach the evidence One file only.10 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Please explain any evidence you are supplying Photos Do you wish to attach photos? Upload up to 6 photos Yes No Attach photo One file only.10 MB limit.Allowed types: gif, jpg, jpeg, png. Attach photo One file only.10 MB limit.Allowed types: gif, jpg, jpeg, png. Attach photo One file only.10 MB limit.Allowed types: gif, jpg, jpeg, png. Attach photo One file only.10 MB limit.Allowed types: gif, jpg, jpeg, png. Attach photo One file only.10 MB limit.Allowed types: gif, jpg, jpeg, png. Attach photo One file only.10 MB limit.Allowed types: gif, jpg, jpeg, png. Authority for an agent to act Do you wish for a third party to act on your behalf in this claim? Yes No Agent details Name Email Phone Address City/Town Electronic confirmation Council will investigate the circumstances surrounding your claim to establish whether or not Council has any legal liability. Completion and acceptance of this form does not represent an admission of liability or a waiver of its rights on the part of Council. Your claim will be subject to investigation and the findings assessed on their own merits. Council may refer your claim to its insurer or to another third party in managing or investigating the claim. Council will endeavour to respond to claims as quickly as possible. However the processing of claims is dependent on the supply of relevant information and assessment of your claim may take some time to complete. I confirm the information is accurate and correct CAPTCHA Leave this field blank