Application for Making a Claim Against Council for Alleged Injury or Loss

Please complete the form with as much relevant information as possible.

Once a claim has been made, Council will investigate the circumstances to establish whether or not Council has any legal liability. Completion and acknowledgement of the claim does not mean Council is liable.

Council will endeavour to respond to a claim as quickly as possible, and within 21 days of receipt. However, the processing of claims is often dependent on the supply of relevant information and may take some time to assess.

Alternatively, you may wish to lodge a claim against your own insurance policy, following which your insurer may consider seeking cost recovery against Council.

In dealing with claims, Council works within the framework of its legal obligations and responsibilities under the Civil Liability Act 2002. Among other provisions, this Act recognises that functions exercised by a public authority (such as Council) are limited by financial and other resources. For further information on these provisions under the Civil Liability Act can be found by following this link.

If a claim relates to a site or project managed by a Council contractor, the claim may be referred to the contractor for assessment.

As part of submitting the claim form, you are also asked to include any other relevant supporting documents including but not limited to:

Photographs of the hazard
Photographs of the damage/injury
Maps or diagrams of the alleged incident location
Medical certificates or copies of other medical reports
Receipts, quotes or invoices for costs incurred

Part 1 - Claimant Details

Full name *

Postal address *

Street address *

Suburb/Town *

State *

Postcode *

Phone *

Email Address *

Do you agree for all Council correspondence in relation to this submission to be sent to you by email? *

YesNo

If No please specify your preferred contact method

Part 2 - Details of Incident Alleged

Date of incident *

Time of incident

Location of incident (if the alleged event occurred on a QPRC-managed road, please specify the nearest crossroad as well as the distance to any landmarks) *

Weather and lighting conditions

Road surface (if applicable)

Did you contact QPRC at the time of the event?

YesNo

If yes, please list Customer Reference Number if known.

Description of the incident alleged *

Why do you belive QPRC is responsible?

Part 3 - Compensation sought

Please specify the total amount you are claiming

Please specify details of any other loss or damage claimed

Please note that the request for this information must not be seen as an automatic acceptance of liability. All claims are assessed based on their own merit.

Part 4 - Insurance

Have you claimed against your insurer?

YesNo

If Yes, please include details of your insurance provider and claim reference number

Part 5 - Witness

Did anyone other than the claimant witness the event? *

YesNo

Witness name

Witness address

Witness contact number

Witness contact email

Part 6 – Attachments and Supporting Documentation

Please indicate which of the following you have included as attachments and would like considered as part of this claim assessment.

If other please specify

Supporting documents

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Part 7 – Submission and declaration

Council will investigate the circumstances surrounding your claim to establish whether or not Council has any legal liability.

Completion and acceptance of this form does not represent an admission of liability or a waiver of its rights on the part of Council.

Council may refer your claim to its insurer or to another third party in managing or investigating the claim. Council will endeavour to respond to claims as quickly as possible. However, the processing of claims is dependant on the supply of relevant information.

I have read and understand all of the above

YesNo

I confirm that all information I have provided to QPRC as part of this claim submission is correct and accurate

YesNo

Signature

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