Injury or Damage Claim

Full Name

Email

Phone

Home Address

On which date did the incident occur?

What time did the incident occur?

What were the weather conditions at the time of the incident?

Sunny

Cloudy

Windy

Rainy

Address of Incident

Please enter the address of the incident location

Street Address

City

Postcode

Nearest Crossroad

Please describe the location of the incident

Please describe what happened to cause the injury or damage

Insurance

Compensation Request

Please describe what compensation you are seeking from Council

What amount of compensation are you seeking from Council?

You will need to provide us with information to show what has happened, and you will need to provide us with the evidence to support your reason for claiming compensation from Council.

This would include photographs, quotes for repairs, reports etc.

It is up to you to provide proof, and Council cannot help you with this.

Please email all relevant evidence to liabilitynotifications@wollondilly.nsw.gov.au.

Disclaimer

You must read and acknowledge the following conditions before you lodge a claim.

I understand that by accepting this form and the information that it contains, Council does not automatically accept liability for the incident described

Signature

Injury or Damage Claim

Address of Incident

Insurance

Compensation Request

Disclaimer

Latest News