L716 Notice of Claim

Notice Of Claim

Notice Of Claim

Law Department

Risk Management & Claims

P.O Box 2100, Station M

Calgary, AB T2P 2M5

Phone: 403-268-5443 Fax: 403-268-8257

Email: claims@calgary.ca

Notice of Claim

L 716 (R2023-10)

ISC: Confidential

For completion by the claimant (party claiming the Municipality is responsible for damages to their property or person).

1. PERSONAL INFORMATION OF CLAIMANT

Title

Last name (required)

First name (required)

Address (required)

City (required)

Province (required)

Postal code (required)

Format: A9A 9A9. First letter can't be D, F, I, O, Q, U, W, or Z

Date of birth (bodily injury only)

2. BUSINESS INFORMATION (if applicable)

Business name

Address

City

Province

Postal code

Format: A9A 9A9. First letter can't be D, F, I, O, Q, U, W, or Z

3. DAYTIME CONTACT INFORMATION

Home phone (required)

Format: 403-123-4567

Work phone

Format: 403-123-4567

Cell phone

Format: 403-123-4567

Email (required)

4. CLAIM INFORMATION

Date of incident (required)

Format: MM/DD/YYYY

Time of incident (required)

12-hour time format: 1:23, then choose AM/PM

Location of incident (required)

Description of what happened (required. Max. 10,000 characters.)

Description of claimant's injury, property damage or loss (required. Max. 10,000 characters.)

Identify City employee involved

Type of City vehicle

City Vehicle licence number, unit number or bus number

5. CLAIMANT VEHICLE INFORMATION (if vehicle involved in incident)

Licence plate number

Year

Make

Model

6. PROPERTY OR MOTOR VEHICLE INSURANCE INFORMATION

Insurer

Policy number

Claim number (if applicable)

7. AMOUNT OF CLAIMANT'S PROPERTY DAMAGE OR LOSS (Attach two estimates of the cost of repairs at section 9)

Item

Amount

Temp Item

Temp Amount

Total Amount

Damaged List

8. WITNESSES (if any)

Last name

First name

Phone

Format: 403-123-4567

Temp Last Name

Temp First Name

Temp Phone

Witness List

9. ATTACHMENTS (estimates, receipts, photos, etc)

Acceptable formats are audio, video, image, text, pdf, word and excel. Each file must be under 5MB.

If required, send additional or oversized files to claims@calgary.ca in an email.

Attached File Names

Note: If the alleged damages might have occured as a result of work being performed by a contractor on behalf of the City your claim will be forwarded to the Contractor.

The personal information is collected under the authority of Section 33(c) of the Freedom of Information and Protection of Privacy Act (Alberta). It will be used for the purpose of processing and investigating the reported claim. If you have questions regarding the collection of this information please contact:

Leader, Claims

Risk Management and Claims, Law Department

City of Calgary

Phone (403) 268-5443

Upon submission, you will see a Thank You page. If you do not see this page, or experience any technical difficulty, call 311.