HIGHWAYS THIRD PARTY PROPERTY DAMAGE CLAIM FORM

We must protect the funds we handle; successful claims are paid out of public funds. Costs associated with defending unsuccessful or fraudulent claims divert funds from frontline Council services including highway maintenance. If appropriate, your claim may be passed on to a utility company, contractor or other organisation to deal with.

Full Name Telephone Number: & Address

Email Address:

Exact location of Incident: Please provide sufficient details to identify the precise accident location (e.g. outside 57 High Street, ) Date & Time of Incident: Date: Time:

Description of the Incident: Please also provide photographs of the location as without these we will be unable to investigate your claim

Reported To ?: Yes Reference Number Given: No

Vehicle Details: Make/Model: Registration:

Details of Damage Claimed For:

Please provide details of your full claim.

Details of Any Witnesses To The Incident:

STATEMENT OF TRUTH: By signing and returning this form, I confirm that the facts stated on this form are true.

Name: Signature: Date:

Please Note:  This authority is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes. For further information, see http://www.trafford.gov.uk/about-your-council/data-protection/privacy- notices/level-2-fair-processing-notice.aspx or contact Trafford Council’s Audit & Assurance Section on (0161) 912 1275.  Your claim will be forwarded onto the Council’s insurer to handle on our behalf & Amey/One Trafford for investigation. Our insurers may request further information from you before investigations can commence.  If you are in arrears with the Council and the Council admits they are liable for your claim, the Council may seek to deduct these debts before settling your claim.  You may seek your own independent legal advice in respect of this matter.

Please return to: Insurance Team, Trafford Council, Financial Management, 1st floor Extension, Trafford Town Hall, Talbot Road, , . M32 0TH or scan and email to [email protected]

Before returning, please include copies the following (please tick each box):  Photographs of the accident location, along with a map showing the location and your direction of travel.  A copy of your current motor insurance certificate.  A copy of your most recent MOT test Certificate (if less than 3 years old, the V5C). You agree to us checking your vehicle’s tax & MOT status with www.gov.uk/check-mot-status & www.gov.uk/check-vehicle-tax  Copies of any estimates or invoices or repair reports. IMPORTANT: Please ensure that you do not submit originals as we cannot return them.