Property Damage Claim Form

Section 1
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.

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Section 2
Has the issue/defect been reported to Devon County Council?*
- Yes
- The defect/issue 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
Please explain when you were aware that the defect/issue was repaired*

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Section 3 - Pictures
Please provide photos showing the defect (if safe to obtain)
Drop files here or
Photo of damage
Drop files here or
It is important that we receive as much information as possible. Any photographic evidence will assist us when reviewing your claim.

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Section 4 - Personal details
Name*
Title 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*

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Section 5 - Description of incident
Please provide the exact date of the incident*
Date Format: DD slash MM slash YYYY
Please detail the time of the incident*

: HH

MM
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*
Drop files here or
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*

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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*
Date Format: DD slash MM slash YYYY
CAPTCHA

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Section 1