Town of Cochrane

We recommend you contact your insurance company first. They can advise you on how to deal with injury or damage. Your insurance coverage may be more extensive than what you can receive from the Town. Additionally, if your insurer believes Cochrane is responsible for your damage, they may seek compensation on your behalf.

The Town will only provide compensation when found legally liable for the damage sustained. This approach helps to reduce costs for the tax-paying public, who ultimately bear the cost of these claims.

BY PROVIDING YOU WITH THIS FORM, THE TOWN OF COCHRANE DOES NOT ADMIT ANY LIABILITY FOR THE DAMAGES. THIS FORM IS SOLELY USED FOR INVESTIGATION PURPOSES OF THE INCIDENT DESCRIBED BELOW.

At this time, I am choosing to:

Submit a claim

Check this box if you are looking to receive compensation

Report an incident

Check this box if this is for informational purposes only

Type of Incident

Vehicle Damage

Property Damage

Personal Injury

Date and Time of Incident

Location of Incident

Has this incident previously been reported to the Town of Cochrane?

Yes

Date first reported

Provide the name of the individual the incident was previously reported to:

Your Information

Name (first and last)

Company

Phone

Address

City/Town

State/Province

ZIP/Postal Code

Driver's Licence No.

Vehicle Information

Year

Make

Model

Licence Plate No.

Name of Insurer

Policy No.

Full Name of Driver (if different from above)

Phone number of driver

Address of Driver (if different from above)

City/Town

State/Province

ZIP/Postal Code

Where can vehicle be inspected (if required)?

Description of loss/injury

Why do you feel the Town of Cochrane is responsible & what would you like the Town to do?

Supporting documentation (pictures, witness statement, etc.)

Maximum 6 files.
128 MB limit.
Allowed types: gif, jpg, png, svg, pdf.

Was there a witness?

Yes

Name

Phone

Address

City/Town

State/Province

ZIP/Postal Code

Country

Authorization

By completing this form, I solemnly state that the above-mentioned information is true to the best of my knowledge and belief.

Agree

FOIP Statement

The personal information on this form is being collected under the authority of section 33 (c) of the Freedom of Information and Protection of Privacy (FOIP) Act and Part 10, section 340(1) of the Municipal Government Act. Your personal information may be used by the Town of Cochrane for the purpose the information was collected or compiled or for a use consistent with that purpose. Your personal and financial information will be managed in accordance with FOIP. If you have any questions about the collection, use, or disclosure of your personal information, please contact the Town of Cochrane’s FOIP Office at FOIP@Cochrane.ca.

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Claim/Incident Report Form

Your Information

Vehicle Information

Authorization

FOIP Statement