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Incident Report

Note: The Clerk's Department will forward your incident report to the City's Insurance Adjuster. The Adjuster will contact you shortly thereafter.

Personal Information on this form is collected pursuant to Municipal Freedom of Information and Protection of Privacy legislation and will be used for the purpose of processing your submission. Questions about this collection should be directed to: Freedom of Information Coordinator, Office of the City Clerk, 3540 Schmon Parkway, Thorold, Ontario L2V 4A7 or 905-227-6613.

Type of Incident

Personal Injury

Property Damage

Name

Address

Phone Number

How would you like to be contacted

Telephone

Place of Employment

Date of Occurrence

Location of Occurrence

What is the estimated cost of the incident/damage?

Details Occurrence

Independent Witness Information

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Signature

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