Accident/Damages Notification Form

Accident/Damages Notification Form

If you would like to notify Hindmarsh Shire Council of damage to property or motor vehicles, or report an accident/personal injury of an individual, please complete this form.
PRIVACY STATEMENT

We will handle any personal information you have provided in this form in accordance with the Privacy and Data Protection Act 2014. Our privacy policy contains information about how you may access your personal information and seek correction of such information; as well as how to complain about a breach of the Australian Privacy Principles and how we will deal with such a complaint. For more information, please see our Privacy Policy or contact our team on (03) 5391 4444. Your personal information will not be disclosed to any other party unless Council is required to do so by law, has gained your consent to do so or an information privacy principle exemption applies.
I wish to notify Hindmarsh Shire Council of:*

Damage to propertyDamage to motor vehicleAccident/personal injury to an individualOther
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Do you wish to receive all correspondence relating to this incident via:*

PostEmail
Where did the incident occur?*
Please describe the incident that occurred.*
Please describe the weather conditions, road condition, speed travelling and visibility at the time of the incident (where applicable):*
Name and phone numbers of other parties involved/witnesses:*
Please describe injuries or property damage sustained as result of incident:*
Where was medical care received?*
Name of person reporting incident:*

First NameLast Name
Signature of person reporting incident:

Clear
Should be Empty: