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Damage Claim Form

First name:

Last name:

Full address:

City of residence:

Postal code:

Phone:

Email address:

Date form submitted:

Address where damage occurred

Date when the damage occurred:

What time did the damage occur?

Please provide a description of what was damaged and how

Please indicate why you believe the City was responsible for the damage:

Please provide names and identification of any other parties involved:

Is there any other information you feel is important to share?

Use this tool to upload any photographs of the damage (if applicable)

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

Disclaimer

I fully understand that this official notice setting forth the time, place and manner in which I sustained damage must be e-mailed claims@portmoody.ca within two months from the date on which I sustained the damage or in writing to the City of Port Moody 100 Newport Drive, Port Moody BC V3H 5C3. (Section 736 of the "Local Government Act," R.S.B.C. 2015, c. 1)

Important: I acknowledge that the City’s receipt of this notice does not constitute its acceptance of liability for any damage or loss I sustained, nor has the City provided any advice to me regarding the adequacy of this notice. I acknowledge that the City is not prevented by receipt of this notice from arguing the adequacy of the notice.

Do you agree to the disclaimer above?

Yes - I agree to the above disclaimer

No - I do not agree to the above disclaimer