Request for Consideration of Claim

Name*

First NameLast Name

Address*

Address

Address Line 2

SuburbState

Postcode

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: 0400 000 000.

EmailMobileVia 3rd partyOther

Motor vehicle damageProperty damagePersonal injuryOther

Road mangementPathTreeOther

Please ensure you attach the following in this application if you suffered personal injury:

Copies of receipts/invoices for any medical expenses related to the incident
A copy of medical certificates/ report from your treating doctor that confirms the nature of injury sustained and future prognosis.
Details of any claimed loss of earnings together with wage records showing details of your earnings and sick pay which you received
Clear, colour photographs of incident location (with the location/cause of the alleged incident clearly marked with an “X”)
Any other evidence which will support your claim

Please ensure you attach the following in this application if you are claiming for general property / vehicle damage:

Quotes, invoices/receipts relating to the repair or replacement of the damaged property*.
Photographs of the damaged property and area where incident occurred or map/diagram marking site of incident
Clear photographs of roots and trees if you are making a tree root claim.
Any other evidence which will support your claim.

*The provisions of the Road Management Act 2004 require an individual or company seeking compensation for property damage arising from the condition of the roadway to pay the first $1,681 of any claim regardless of liability.

Date and time of incident*

Date

Hour MinutesAM/PM Option

Place of incident*

#, street name, suburb

Nearest landmark*

Action you’d like Council to take in relation to the incident*

Description of what was happening just before the incident happened*

E.g. details of where you were, your direction of travel and the speed you were travelling. What was going on around you..

Please provide details of the exact location

Supporting photographs, maps, or sketches to clearly depict the area where the incident occurred

Description of what happened*

E.g. any action you took to avoid the incident, other people or vehicles in relation to you at the time Include any damage or injury as an outcome.

Additional information of what happened

A sketch or drawing, map or other information that helps us understand what happened

Vehicle year/model*

Vehicle registration*

SealedUnsealedOther

DryWetOther

RainingSunnyFogOther

Speed limit on road*

PoorFairGood

PotholeCorrugationsUndulationsOther

Size of defect on road*

Width, Length, Depth

Any additional details

e.g hazard signs, traffic etc

ConcreteConstructed gravelOther

Lip / uneven surfaceCracked or brokenTree root or other disturbanceOther

Size of defect on path*

Any additional details

UrbanRuralOther

Road reserveNature stripParkPrivate property

Dropping limbsFalling treeTree rootHazard

Size of tree defect*

Any additional details

Witnesses

Rows	First name	Last name	Contact details
Witness 1
Witness 2
Witness 3
Witness 4

One of the most effective ways to avoid confusion about the circumstances surrounding your request for compensation is using photographs of the damage or loss. In the case of injury this may include photos of the injury or medical evidence which will substantiate the claim. Without this information, Council is unable to be sure it is investigating the correct issues.

Please attach repair quotes or invoices/receipts to support any claim for costs below. The request of this information must not be seen as an acceptance of liability and all claims are assessed based on their own merit and any payments made will come from Council funds.

Evidence*

Photos should clearly show the damage to your property, Council’s infrastructure, and the potential defect you are identifying that attributed to this damage. Where possible photos should show measurement of the defect – use common objects that are readily identifiable like coins, keys or pens to demonstrate size if you don’t have a tape measure. Take photos from various angles and provide shots from a distance as well as close ups.

YesNo

Description and details of personal injury*

Amount ($)*

How is this calculated?*

YesNo

Description and details of propery or other damage or loss*

Amount ($)*

How is this calculated?*

YesNo

Please upload quotations for any repair if compensation is being sought

Quotations must be on letterhead from suppliers with ABN provided. If the repair has been paid a receipt may be provided and your bank details will be requested for reimbursement.

YesNoNo but intend to

Insurer*

Claim/ policy number*

Insurer contact*

Insurer phone number*

YesNo

Please be advised the provisions of the Road Management Act 2004 require an individual or company seeking compensation for property damage arising from the condition of the roadway/footpath, to pay the first $1,681 of any claim (the “threshold amount”) regardless of liability (includes motor vehicles, clothing, glasses etc).

YesNo

Reason/s you believe Council is liable for the claimed injury and/or damage

In order to succeed in your request for compensation you will be required to establish that Council caused the alleged loss and/or damage through some form of negligence. In any public liability claim the burden of providing proof of negligence rests with you as the person seeking compensation. Note that Council cannot assist you in this. Photographs demonstrating the magnitude of the area of concern, with a variety of shots and angles to clearly show the situation will assist in understanding you claim on this basis

Completion and acceptance of this form does not represent an admission of liability on the part of Council and/or their insurers. Your Incident Notification and any Request for Compensation will be subject to investigation and the findings will be assessed on their own merits.

Council will endeavour to respond as quickly as possible. However, it can take some time to collate all the relevant information before we are in a position to make an accurate decision on liability. The process takes approximately six weeks. However, this timeframe can be longer due to delays in obtaining information and other factors beyond Council’s control.

Council complies with all its obligations under the provision of the Privacy and Data Protection Act 2014 and is committed to transparency and integrity in all its activities and programs. All information you supply is treated as private and confidential.

Mitchell Shire Council is collecting this personal information for the purpose of assessing your claim against Council. We may disclose any information to our insurance company and/or its representatives, investigators, legal advisors or counsel and to any organisation we consider might have responsibility in respect of this incident.

Please retain a copy of relevant invoices, receipts, and photographs for your own records.

YesNo

I First Name* Last Name* , hereby authorise Name of authorised* , whom I have instructed to act on my behalf, to discuss my request for compensation with a representative of Mitchell Shire Council.

Signature*

Name*

First NameLast Name

Address

Address Line 2

SuburbState

Postcode

Phone Number*

Please enter a valid phone number.Format: 0400 000 000.

Email*

example@example.com

I, First Name Last Name of Address Suburb State Postcode do solemnly and sincerely declare that:

1. All the information contained in this Request for Consideration of Claim is accurate to the best of my knowledge and belief

2. I have, to the best of my knowledge and belief, disclosed all relevant information to Mitchell Shire Council and have not withheld any relevant information

3. Any attached quotation or medical evidence has been prepared for the sole purpose of damage or injury resulting from the incident as described in this Incident Notification.

I acknowledge that this declaration is true and correct, and I make it with the understanding and belief that a person who makes a false declaration is liable to the penalties of perjury.

Signature*

Request for Consideration of Claim

Incident details

Road management notifications

Path notification

Tree notifications

Request for Compensation

Authority for agent to act

Contact details of person authorised to act on your behalf

Declaration