Incident Claim

Claims Handling Information

Please note that the provision of this information should not be considered as an admission of liability on the part of Yass Valley Council.

All claims will be considered without prejudice. The acceptance of a completed claim by Council no way infers negligence on the part of Council, or binds Council to provide compensation. Before Council is obliged to pay compensation for any injury, loss or damage suffered, it must be established that this injury, loss or damage was caused through negligence on the part of Council.

The proof required to establish negligence, can be onerous and quite often you may be better served seeking compensation through your insurer. Should your insurance company consider Council to be negligent, it may seek reimbursement on your behalf.

Should you not wish to make a claim against your own insurance and wish to pursue a claim against Council, please complete the attached claims handling form. If you have any questions, please contact Council’s Coordinator Risk Management on 6226 1477 or 0409 830 157.

All claims will be considered on a “Without Prejudice” basis. Acceptance of a completed claim form
by Council in no way infers negligence on the part of Council or binds Council to provide
compensation.

All sections of this claim form must be completed, unless otherwise noted on the form. All required
evidence, photographs and receipts/quotes must be included for the claim to be assessed.

Name*

First NameLast Name

Email*

example@example.com

Phone Number

Area CodePhone Number

Mobile Number*

Address*

Street Address

Street Address Line 2

CityState

PostcodeCountry

Mailing address is the same as above

Mailing Address

Street Address

Street Address Line 2

CityState

PostcodeCountry

Claim Type*

Property DamagePersonal InjuryMotor VehicleOther

Description of Incident:

This should outline how and when the incident occurred i.e. date and time of incident; a full description of what happened and include applicable relevant items such as direction & speed of travel, weather conditions at the time of the incident (please attach additional information on a separate sheet if required).

Has the incident been reported to Council? If yes, please provide details:

Outline how & when the Incident was reported to Council.

An exact description of where the incident occurred:

Exact location and address, include relevant details such as street name, house number, cross streets, distance from reference points, sketch or map of the area including the exact location of the incident (include photos where possible).

An explanation as to why you believe that Council contributed to the incident:

Description of circumstances surrounding the incident, including any physical factors which may have attributed to the incident (please attach additional information on a separate sheet if required).

Details of any witnesses (if applicable):

Name/address/phone number & relationship

A description of the loss incurred, damage caused and/or injuries suffered:

Supporting documents such as photographs, medical reports or invoices must be included to process your claim.

Other relevant information

Have you lodged a claim with your insurer regarding this incident?

YesNo

Have you enclosed any receipts for medical treatment sought? (Please note, if you are claiming medical expenses and you have not included your receipts, your claim cannot be assessed)

YesNo

Have you enclosed a minimum of two (2) quotes for the repair or replacement of any damaged item/s? (Please note, if you are claiming repair or replacement costs and you have not included receipts, your claim cannot be assessed)

YesNo

Browse Files

PRIVACY

In completing this form, you will be providing “personal information” as defined under
the Privacy and Personal Information Protection Act 1988. Council is collecting this
information for the purpose of assessing your claim. This information will only be used
for the purpose it was collected and may be disclosed to relevant third parties for the
purpose of assessing your claim.

Declaration*

I declare that the information provided on this form and all other supporting documentation (including photographs) in relation to my claim is, to the best of my knowledge, accurate, relevant and complete.