Road Defect Claim Form

Completion of this form and its submission to Stirling Council cannot be construed as binding the Council in liability to the claimant.

Road and Footway Defect Claim Form

Claimants details

Name *

Telephone

Email *

Date of birth *

Please enter first line of address including house no

First line of address *

Please enter Town

Town *

Please enter Postcode

Postcode *

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: Tuesday, October 29, 2019 4:50 PM