Make a claim 1Introduction2Incident3Your details4Review You can use this form to Make a claim if a Council asset has caused injury or damage to your property or vehicle. To complete this form, tell us your contact details about the incident, including the date and time why you think Council is responsible the amount you are claiming Include photos and documents to support your claim. It will take around 10 minutes to complete this form. After you complete this form we will send you an email to confirm your submission send you a reference number within 10 business days What happens with your information? We record your information on our customer database to give you a better experience, including carrying out and responding to your requests. See our Privacy Statement for more information. What is the reason for your claim? * RequiredPlease selectTrip, slip, fallTree root damageFallen tree/branchBlocked drainRoad condition/damage to vehicleOtherVehicle registration number * Required Vehicle make and model * Required Date * RequiredPlease select date of the incident DD slash MM slash YYYY Time of incident * Required Amount you are claiming * RequiredAddress of the incident * RequiredYou can select a location using the mapZoom in and drag the 'map pin' to select a precise location. If you don't know the exact address of the incident, you can provide an approximate location. How did the incident occur? * RequiredWhy do you think Council is responsible? * RequiredUpload supporting documentsFor example, photos, repair quotes, invoices, receipts or professional reports. You can upload a maximum of 4 files at 4MB each.Allowed file types: jpg, jpeg, png, doc, docx, pdf Drop files here or Select files Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 4 MB, Max. files: 4. Maximum file size - 4 mega bytes. Name * Required First name Last name Email Enter email Confirm email Phone number * RequiredPostal address * Required Street address or PO Box Address line 2 Suburb / City State Post code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Preferred method of contact * Required Email Phone Post I have read and accept Council's Privacy Policy and understand how my information will be used. * Required Yes Please review your information. If you notice errors please use the numbered page navigation or the 'previous' button to make changes. If all information is correct, please click the 'Submit' button to complete this form. {all_fields:exclude[9, 11, 23]}PhoneThis field is for validation purposes and should be left unchanged.
