Claim for Compensation Form | Wagga Wagga City Council

Your details

Full name

Postal address

(If your address can't automatically be found, you can still enter it manually)

Contact number

Preferred method of contact

Email
Phone
Post

Details of claim

Was the incident reported to Wagga Wagga City Council Customer Service?

If yes, please provide the Customer Request number

Reason for your claim

Personal injury
Damage to your property
Damage to your vehicle
Other

Date of incident

Time of incident

Be as specific as possible, for example, '7:30am', 'approximately 7am' or 'between 7am and 8am'

Location of incident

Please enter the property address or drag the pin to mark the exact incident location

Description of the incident

Provide as much detail as possible including contributing factors, e.g. weather, speed.

Why do you believe Wagga Wagga City Council is liable for the incident?

Please provide details of what you are claiming for

Total amount you are claiming for

Have you claimed against your insurer?

Motor vehicle details

Registration number

Make and model

Year made

Name of vehicle's owner

Evidence

You are required to establish that we 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 you as the person seeking compensation. We cannot assist you in this.

Evidence and supporting documentation are required to evaluate your claim if this information is not provided it may delay your application.

Supporting documentation

e.g. quotations, tax invoices, inspection reports or out of pocket medical expenses. Please provide at least two quotations or one tax invoice, as applicable. Please note: maximum file size is 5MB

Photographs

One of the most effective ways to avoid confusion about the circumstances surrounding your claim is through the use of photographs. Council will use photographs to ensure we are investigating the correct location and/or issue. Only take photographs if it is safe to do so.

Your photographs need to show the following (as applicable). Other photos can be attached as relevant.

The property damage sustained, e.g. car door, tyre rims or windscreen
A photo clearly showing the side where the damage occurred (e.g. passenger/diver’s side)

Personal injury examples:

A clearly marked area where the incident/accident occurred
A clearly marked area where the incident/accident occurred e.g. section of footpath
A photo clearly showing the surrounding area in relation to the alleged hazard

Please note: maximum file size is 5MB

Authority for an Agent to Act

Do you wish for a third party to act on your behalf in this claim?

Full name

Postal address

(If your address can't automatically be found, you can still enter it manually)

Contact number

Relationship to claimant

Declaration

Completion and acceptance of this form (including completion of the Authority for an Agent to Act, when completed) does not represent an admission of liability on the part of Wagga Wagga City Council and/or our insurers. Your claim for compensation will be subject to investigation and will be assessed on its own merits.

I declare that the information supplied to Wagga Wagga City Council in this claim form is true and correct and confirm the statements are honestly made.