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Submit a Claim

By submitting these details you are creating a claim for compensation against Haldimand County. Submission of this form does not necessarily result in compensation as Haldimand will only compensate when legally liable to do so, nor does this commence legal action against the County. It is recommended that you review the Risk Management, Insurance and Claims Page before submitting a claim.

What type of claim are you submitting?

Auto damage claim

Property damage claim

Bodily injury claim

Contractor claim

Claimant's information

First name

Last name

Address

Town/City

Province

Postal code

Phone

Incident information

Date of incident

Time

Incident location

Town/City

Description of incident

Was the OPP contacted?

Yes

State why you feel the county is responsible for your damage or injury and what you would like the county to do.

Please include photos where possible

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Acknowledgement

I agree that everything submitted is true and accurate to the best of my knowledge.

Date

Notice of Collection

Personal information on this form is collected under the authority of the Municipal Act, 2001 and the Municipal Freedom of Information and Protection of Privacy Act and will be used to process your claim, including the possible disclosure to third parties to verify and investigate this claim. Questions regarding this collection or disclosure of this record can be sent to the FOI Coordinator at 905-318-5932.