* indicates that the field is mandatory.
This form is used to report damage or incidents which you believe Council may be subject to liability for.
Surname *
Given Names *
Residential Address
Postal Address (if different to above)
You must provide at least one of the below points of contact.
E-Mail Address
Phone Number
Mobile Phone
Details of the event that occurred (what happened, how). *
Where did the event occur? *
When did the event occur (date and time)? *
Details of injuries or damage suffered. *
As the claimant, how do you allege Council is liable? *
Name/s and Address/es of any witnesses. *
If known, please detail amount being claimed or outcome sought. *
Attachment File 1
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Attachment File 2
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Attachment File 3
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Attachment File 4
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Attachment File 5
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