Required fields are marked with asterisks (*)

Incident Report

This Incident Report is for members of the public to complete should they believe the City of Peterborough has been negligent and they have suffered property damage or personal injury.

Contact information

Name

Address

City

Province

Postal code

Phone number

Email address

Incident information

Date of incident

Time of incident

Type of incident (choose all that apply)

Bodily injury

Property damage

Vehicle collision

Please describe the incident

Location information

Street address

Cross street

Location comments

Bodily injury details

Please provide a description of the injury

Please attach any additional information relating to the incident

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Please provide a description of medical aid received

Property damage details

Please provide a description of the property damage. Please include estimated cost.

Vehicle information

Year, make and model of vehicle

License plate number

Name of registered owner

Please provide a description of the vehicle damage

Speed

Insurance company

Policy number

Were the police contacted?

Yes

Police incident number

Officer badge number

Any additional information you feel would assist with our investigation (photos, estimates etc.) can be sent directly to claims@peterborough.ca.

If it is determined that the area involved in your incident was under control of a contractor, do you give consent to have the information contained in your submission forwarded to the contractor for investigation?

Yes

Would you like an email copy of your Incident Claim form?

Yes

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