Type of Claim

Reported By

Email Address (to receive acknowledgement)

Name of Owner of Damaged Property

Name of Injured Person

Address of Owner, Including Postcode

Address of Injured Person, Including Postcode

Phone Number of Owner

Phone Number of Injured Person

Date of Birth of Owner

Date of Birth of Injured Person

NI Number of Owner

NI Number of Injured Person

Occupation of Owner

Occupation of Injured Person

Incident Date

Incident Time

Brief Description of Incident

Enter Location or Click to Find Location On a Map

House No. or Building Name or Location

Street Name

City

Post Code

Is The Damaged Item a Vehicle?

Vehicle Make and Model

Vehicle Registration Number

State the Items Damaged

Describe What Damage was Caused

Describe The Injury

What part of the Body Was Injured

Name of GP or Hospital Visited or state None

Address of GP or Hospital Visited or state None

Explain Why You Consider the Council Responsible

Please use this area to include any further information

Do You Wish to Add a Witness

Witness Name

Witness Email Address

Witness Address Including Postcode

Do You Wish to Add Another Witness

Witness 2 Name

Witness 2 Email Address

Witness 2 Address Including Postcode

Please attach any photos or documents to support the claim

Data Protection

Telford & Wrekin Council are collecting your personal data to facilitate your insurance claim being processed. Personal information is being processed under Article 6(1)(c) and (1)(e) and Article 9(2)(e), (2)(f) of the Data Protection Act 2018.

Telford & Wrekin Council will securely share this information with the Councils insurance provider/legal advisors and will only share your information where it is legally required / permitted to do so.

For further information on the Councils privacy arrangements please access the Councils privacy notice on its website.

Declaration

I certify that the information I have given is true to the best of my knowledge and belief. Please note any claims made which are found to be untrue will be investigated as potential fraud and referral may be made to the police.

I confirm I have read and complied by the declaration above

Who is completing the declaration

Relationship to Claimant

SEND