Any information which you provide on this on-line form will be
Personal information on this form is collected under the authority of the Municipal Act, 2001, S.O. 2001, C.25 and will be used to
process your claim with the City of Brockville. Questions about the collection of this personal information should be directed to the Risk Management Coordinator, 1 King Street West, P.O. Box 5000, Brockville, ON K6V 7A5 (T) 613-342-8772 ext. 4485.
NOTE: Be aware that there is a 10 day notice for providing the City with Notice of certain types of claims and a two year limitation period for bringing an action in respect to all claims.
Personal Information of Claimant
Contact Information (if different from above)
Identify the employee or section report was made to
Witness Information (1)
Witness Information (2)