Name of Claimant(s) Address of Claimant(s) Address Town Province Postal Code E-mail Address of Claimant(s) Phone Number of Claimant(s) Nature of Claim Date of Event or Accident Time of Event or Accident Address of Accident Address Town Province Postal Code Explanation of accident or event on which claim is based Amount claimed (please attach supporting documentation below, if possible) $ Supporting Documentation Unlimited number of files can be uploaded to this field.64 MB limit.Allowed types: jpg, jpeg, png, txt, rtf, html, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3. Reason for alleged Town responsibilityIf claim involves property damage, please provide the following insurance information below: Name of Claimant's Insurance Company Address of Claimant's Insurance Company Address City/Town Province Postal Code Claimant's Insurance Policy Number Date of Submission Personal information contained on this form is collected pursuant to the Freedom of Information and Protection of Privacy Act/Municipal Freedom of Information and Protection of Privacy Act and will be used for the purpose of responding to your claim. Questions about this collection should be directed to the Director of Corporate Services/Clerk of the Town of Lincoln. CAPTCHA Leave this field blank
