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

Claimant's Name

First Name

Last Name

Claimant's Address

Street Address

Address Line 2

City

State/Province/Region

ZIP/Postal Code

Country

Phone

Date of Incident

Time of Incident

Location of Incident

Details of Incident (Please provide SPECIFIC information regarding the incident and type of damage)

If you are seeking compensation, please specify dollar amount.

If you are seeking compensation, please attach copies of estimates, receipts, photos etc.

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

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.

Signature of Claimant is Required. Please acknowledge that you are the person who is named in this claim and that all information is accurate to the best of your knowledge.

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Date Damage Claim Form was Submitted by Claimant

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 info@greaternapanee.com.

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