Road Defect Claim Form

Your Questions

General Incidents Form

Home & Residence Form

Road and Footway Defect Claim Form

Claimants details

Full Name *

Please enter first line of address including house no

Address *

Please enter Town

Postcode *

Telephone

Email *

Date of birth *

Are you submitting a claim on behalf of someone else?

Yes

Incident Details

Describe the incident and how it occurred *

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

Description of defect location *

Road name *

Town incident occurred

Incident date: *

Incident time:

Direction of travel *

Type of Defect

If other, please specify

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

Yes

Has the defect now been repaired? *

Yes

Don't Know

Last updated: Monday, July 13, 2020 8:15 AM