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Road Defect Claim Form

Road Defect Claim Form

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General Incidents Form

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Liability

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

Consent

I give permission to store and process my data *

Claimants details

Name *

Address *

Telephone

Email *

Date of birth *

Are you submitting a claim on behalf of someone else?

Yes

No

Agent name

Address

Email

Incident Details

Describe the incident and how it occurred *

Description of defect location *

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

Road name *

Town *

Incident date: *

Incident time:

Direction of travel *

Type of Defect

Cause *

If other, please specify

What is the pothole depth

What is the size of the pothole

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

Yes

No

Did you report the defect prior to the incident?

Yes

No

Please provide the date and time reported

Has the defect now been repaired? *

Yes

No

Dont know

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Insurance Online Forms

Road Defect Claim Form
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