notice of claim - september 2019
Insurance fraud is a crime and liable to prosecution
Stockton on Tees Borough Council is committed to protecting the public funds it handles and, in
order to prevent and detect fraud, it may share information relating to claims with other
organisations and public bodies. The deliberate provision of false or misleading information will
always be reported to the Police for investigation and action will be taken to recover costs.
This form is issued to allow the Council to fully investigate your claim and does not imply any admission of
liability, nor that any payment will be made in respect of the claim. Please give full and precise information
relating to your claim as this will help to minimise any delays which could arise in resolving this matter.
Full Name: Address:
Date of Birth :
Email Address:
National Insurance No:
Exact Date of Incident: Exact time of Incident:
Exact Location of Incident/Loss/Damage to vehicle/property:
Explanation of how Incident/Loss/Damage to vehicle/property occurred:
Why do you think the Council is at fault?
Details of Injuries/Loss/Damage to vehicle/property:
If injury resulted in time off work, please give dates of absence:
Did you attend Hospital as
a result of this accident? Yes No
If YES, please advise which Hospital attended:
Please also advise the date attended Hospital:
Were there any Witnes
ses? Yes No If Yes please complete the section below for each witness
The Council is required to deal with claims in accordance with the Pre-Action Protocol of the Civil
Procedure Rules. This requires that an acknowledgement toyour claim is issued within twenty one days
of receipt. The Council then has afurther period of 90 days to complete its investigations into your claim.
notice of claim - september 2019
Name: Name: Name:
Address: Address: Address:
Please provide photos of the accident location, of your injuries (if applicable), and./or of the damaged
property i.e. clothing, vehicle etc.
Description of Damaged Article(s)/Property/Loss/Damage to vehicle (for vehicle damage claims please submit a
complete copy of the Vehicle Registration document (V5).
Date of Purchase:
Original Cost of damaged property/articles (please supply original receipts/evidence of purchase where available):
Cost of Repair/s or Replacement (please provide 2 written quotations):
Is the item available for inspection? Please submit photos.
Signed: Date:
Please return form to:
Stockton on Tees Borough Council
Insurance Section
Municipal Buildings
Church Road
Stockton on Tees
TS18 1LD
Email to:
Disclosure of Information
We may check information provided by you, or information about you provided by a third party, with other information held by us. We
may also get information from third parties, or give information to them to check the accuracy of information, to prevent or detect
crime, or to protect public funds in other ways, as permitted by law.
We will not disclose information about you to anyone outside Stockton on Tees Borough Council or use information about you for
other purposes unless the law permits us to.
Stockton on Tees Borough Council is a registered data controller. If you want to know more about what information we have about
you, or the way we use your information, please contact the Information Governance Team. You may also review the Council’s
Privacy Notices on theStockton on Tees Borough Council website.