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Claim Submission Form

If you have suffered a loss or damage for which you believe the Township of Wilmot may be responsible, you must provide the information below for the Township to consider your claim.

Note: This claims process does not mean that the Township of Wilmot is accepting liability for your claim, nor does it waive any legal rights that the Township may be able to rely on in matters such as these.

Applicant Information

Full Legal Name

Street Address

Town

Postal Code

Telephone Number

Email Address

Claim Information

Date of the Incident:

Approximate time of the incident:

Please provide the exact location of the incident:

Please provide a detailed description of the incident and the reason(s) you believe the Township of Wilmot is liable for the alleged injuries/damages sustained.

Please provide a detailed description of your alleged damages or loss, together with copies of any available invoices, estimates, and any other applicable documentation.

Please provide copies of all applicable invoices, estimates, and any other documentation in support of your claim.

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

Please sign this claim letter (electronic signature is acceptable).

Clear

Please enter the date you signed this notice of claim.

Any personal information that is collected is done in accordance with the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and will be shared with the Waterloo Region Municipalities Insurance Pool and used to contact you and process your notice of claim. Questions about this collection should be directed to:

Township of Wilmot
Municipal Clerk
60 Snyder's Road West
Baden, Ontario N3A 1A1
Telephone: 519-634-8444
Email: clerks@wilmot.ca

Contacts