Make a Claim Against the Region or the Niagara Transit Commission

Personal information on this form is collected pursuant to the Municipal Freedom of Information and Protection of Privacy Act and will be used for the purpose of reviewing your claim.

Niagara Region does not accept written notices of lien claims through its online claims intake process or by email. Written notices of liens must be served on Niagara Region in the manner according to the Construction Act.

* = Required

Claimant Information

* First name

* Last name

Organization / business name (if applicable)

* Address

* City / town

Province

* Postal code

Home phone xxx-xxx-xxxx

Work phone xxx-xxx-xxxx

Ext.

Contact method Home phone
Work phone
Email

Details of the Claim

* Is this is a Niagara Transit Commission related claim? Yes
No

* Incident date

Time :

Incident location

* City / town

Details and description of incident

Claim amount

(attach copies of invoices, estimates, receipts near bottom of page)

Vehicle Involved

This claim involves vehicle damage due to roadway disrepair

Vehicle Details

Vehicle year

Make / model

Mileage

Owner

Incident Details

Driver's name (at the time of the incident)

Passengers (In vehicle at the time of the incident)

Direction of vehicle

Speed of vehicle km/h

Condition of road

Describe the weather conditions at time of incident

Describe the exact location of the disrepair on the roadway
(Was the disrepair located on the paved portion or shoulder area?)

Describe the disrepair on the roadway (include dimensions)

Describe any signs that warn of road disrepair
(e.g. construction signs, traffic cones, bump ahead)

List names of any independent witnesses

There was construction in the area

I have notified my auto insurance company

Supporting Documentation

Submit electronic documents (photos, reports) supporting my claim. Each file has to be a maximum of 5 MB, and all files must be less than 10 MB.

Only PDF, JPG, DOC(X), XLS(X), PNG and TXT formats will be accepted.

Attachment 1

Attachment 2

Attachment 3

I will send other documentation by mail.

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.

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