Property – Claim Notification Form

This claim form MUST be completed in full. Failure to fully complete this form may result in your claim being delayed.

Claimant's Details

Date of incident:

Required

Title:

Required

First name:

Required

Last name:

Required

Property number/ name:

Required

Street name:

Required

Town:

Required

Town:

Required

Telephone:

Email:

Required

What is the claim for?

RequiredVehicle damageProperty damage

Vehicle damage

Details of damage:

Required

Vehicle make/model?:

Required

Registration?:

Required

Property Damage

Please provide a description of the property/losses claimed for:

Required

Incident Details

Time of incident:

Required

Where did the incident happen?

Required

Photography

Please provide any photographs you have of the incident in .jpg format. If you have more than 3 photos, you can supply these once you've been allocated a Claim Handler.

Photograph 1:

Photograph 2:

Photograph 3:

Description of incident

Required

Names and addresses of any witnesses to the incident

Required

Was the incident reported?

YesNo

If yes, please provide who it was reported to and when?

Why do you believe the council are to blame for the incident?

Required

Statement of Truth

We will shortly have more information here. Please bear with us.

I certify that the information I have given is true to the best of my knowledge and belief.

Personal data

I consent to my personal data being used to enable Sandwell Children's Trust to respond to my enquiry, in line with our Privacy Policy