Personal injury claim form - Roads and transport

Section 1 – data protection

Data Protection Fair Processing Statement: The information which you provide on this form will be held by Devon County Council and may be shared with the Council’s contractors, solicitors and insurance company if necessary. Please read our privacy notice for more information relating to how we handle your data.

Section 2 – reporting the issue

Has the issue/defect been reported to Devon County Council?

Yes

Defect has been repaired

Please provide the reference number for the report*

Please report the issue/defect here – Report a Problem Page. Once you have reported the issue/defect please return to the claim form with the reference number

Do you also wish to make a claim for any property damage?*

Yes

No

Please explain when you were aware that the defect/issue was repaired*

Section 3 – Pictures

Please provide photos showing the defect (if safe to obtain)

Drop files here or

Max. file size: 40 MB.

Photos of damage/injuries

Drop files here or

Max. file size: 40 MB.

It is important that we receive as much information as possible. Any photographic evidence will assist us when reviewing your claim.

Section 4 – Personal details

Name*

First Last

Address

Street Address Address Line 2 Town Post Code

Email

The inclusion of an email address will enable us to process your claim quicker

Phone*

Section 5 – Description of incident

Please provide the exact date of the incident*

Please detail the time of the incident*

:

Please provide as much information as possible as to the location of the incident (road name, adjacent landmarks)

Please provide a map, highlighting the exact location of the incident*

Max. file size: 40 MB.

You must provide a map highlighting the correct location for us to accurately assess your claim

Describe the incident (exactly what happened and your opinion of the cause of the incident). please provide as much information as possible*

Section 6 – details of injuries

Description of injuries sustained*

Please provide as much information as you feel relevant

Did you attend Hospital*

Yes

No

Hospital name

Please describe the damage sustained to personal property*

Please detail the cost of damages*

Please attach copies of your receipts*

Drop files here or

Max. file size: 40 MB.

Section 7 – Declaration

I understand that any suspected fraudulent claims will be vigorously investigated and where fraud is proven Devon County Council will seek to recover costs which could be pursued through the criminal or civil courts.

I confirm that I am aware that this is a legal document and confirm that the statements contained in this document are true and a matter of fact, to the best of my knowledge and belief.*

I agree

Date form signed

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