Required fields are marked with asterisks (*)

City of St Catharines Claims Form

Claimant's Information

Please note: Personal information on this form is collected pursuant to the Municipal Act, 2001 and will be used for the purpose of administering your claim. Questions regarding this collection of personal information can be directed to the City Clerk.

First Name:

Last Name:

Organization / Business Name (if applicable)

Address

City

Province

Postal Code

Home Telephone Number

Work Telephone Number

Email Address:

Incident Overview

Was a vehicle involved in the incident?

Yes

Have you notified your home and/or auto insurance company of the incident?

Yes

Was there any construction in the area of the incident?

Yes