Public Liability Insurance Claim Form

Privacy collection statement:

The personal and/or health information being collected on this form by Council is for the purpose of investigating and considering your claim.  Some of the information we ask is required under the Road Management Act 2004. Where required we may disclose your information to our insurers, advisers, investigators, legal adviser and to other organisations we consider might have responsibility in respect to this incident.

Your information will be stored in Council’s Customer Database and used to identify you when communicating with Council and to deliver services and information to you. For further information on how your personal information is handled, visit Council’s Privacy Policy.

Applicant Details
Preferred Contact Number Type (required)
Claimant Details
Claimant Confirmation (required)
Preferred Contact Number Type (required)

Note: that we will contact claimants who have requests submitted by another party to ensure that the applicant is authorised.

Incident Cause
Primary Cause (required)

Please Note:

You cannot lodge a consideration of claim request for less than $1640 because there is State Government legislation (Section 110 of the Road Management Act 2004) that applies to you and Wyndham City Council in these situations.

The legislation states that road authorities are not liable for the first $1640 of property damage expenses resulting from the road conditions, regardless of the specific condition of the road and whether the authority (such as Wyndham City Council) has been negligent. This legislation and threshold is managed by the State Government as opposed to Wyndham City Council.

Note that if you have claimed this loss against your motor insurance policy, you are not entitled to claim beyond your excess amount.

Secondary Cause
Secondary Cause
Secondary Cause
Secondary Cause
Secondary Cause
Have you reported the issue that caused the incident? (required)
Incident Details
Claim Details
Loss type (select all applicable) (required)
Supporting Documentation & Declaration

Note: 

  • maximum of 2mg per support document upload
  • maximum of 5mg for video upload
  • total 20mg per form submission
Maximum 7 files.
Allowed types: jpg png pdf doc docx.
2 MB limit per file.
One file only.
Allowed types: mov mp3.
5 MB limit per file.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
20 MB upload limit per form.