Road Defect Claim Form

Your Questions

General Incidents Form

Home & Residence Form

Road and Footway Defect Claim Form

Claimants details

Full Name *

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Address *

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Postcode *

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Telephone

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Email *

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Date of birth *

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Are you submitting a claim on behalf of someone else?

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Yes

Incident Details

Describe the incident and how it occurred *

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Description of defect location *

Please provide an exact description of the defect locus with reference to nearby landmarks

Road name *

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Town incident occurred

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Incident date: *

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Incident time:

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Direction of travel *

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Type of Defect

If other, please specify

Were you aware of the defect prior to the incident? *

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Yes

Has the defect now been repaired? *

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Yes

Don't Know

Last updated: Tuesday, January 26, 2021 2:53 PM