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Required fields are marked with asterisks (*)

Our employees are instructed to provide this form to you and are not authorized to accept responsibility for claims made.

Claimant's Name

Claimant's Address


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This request for information does not constitute an acceptance of your claim but permits the Corporation of the Town of Greater Napanee or its Insurance Representative to properly record and investigate your claim.


Personal informaton on this form is collected under the authority of the Municipal Act and Insurance Act of Ontario and is used to process claims made against the municipality. For further information please contact

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