Submit a request for compensation

Have you already reported this incident to the City?

Yes
No

Please provide either the reference number you were given or the full name of the person who reported the incident.

Date and time of incident.

Describe the injury, damage, and/or loss.

Describe how the accident, incident or loss occurred?

Provide details of the weather and lighting at the time of the incident

Explain why you believe the City is responsible, including what the City should have done and how this would have prevented the incident

Describe the exact location of the incident

Please upload a colour photo of the area, marked with an X identifying the precise location of the incident.

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Please check file typePlease provide Please upload a colour photo of the area, marked with an X identifying the precise location of the incident.

Are you claiming medical expenses?

Yes
No

Please provide Are you claiming medical expenses?

Upload a medical report including clinical notes, pre-incident health, current condition in relation to the incident, details of your prognosis, details of the need for current and future treatment, and any specialists reports

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Please check file typePlease provide Upload a medical report including clinical notes, pre-incident health, current condition in relation to the incident, details of your prognosis, details of the need for current and future treatment, and any specialists reports

Upload copies of all invoices for medical expenses

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Please check file typePlease provide Upload copies of all invoices for medical expenses

Upload details of any amounts you have claimed or are entitled to claim from Medicare or private health insurance

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Please check file typePlease provide Upload details of any amounts you have claimed or are entitled to claim from Medicare or private health insurance

Are you claiming compensation for property damage?

Yes
No

Please provide Are you claiming compensation for property damage?

Provide full details of the damage

Please provide Provide full details of the damage

Upload photos of the property damage

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Please check file typePlease provide Upload photos of the property damage

Upload a quotation or an invoice for repair or replacement of each item

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Please check file typePlease provide Upload a quotation or an invoice for repair or replacement of each item

Upload a second quote or an invoice for repair or replacement of each item

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Is your property damage a result of the condition of the roadway or a footpath?

Yes
No

Please provide Is your property damage a result of the condition of the roadway or a footpath?

Under the provisions of the Road Management Act 2004 an individual seeking compensation for damage arising from the condition of the roadway or footpath is required to pay the first $1,681. Is your claim under this threshold?

Yes
No

Please provide Under the provisions of the Road Management Act 2004 an individual seeking compensation for damage arising from the condition of the roadway or footpath is required to pay the first $1,681. Is your claim under this threshold?

Are you claiming other expenses?

Yes
No

Please provide Are you claiming other expenses?

Provide a list of the expenses you are claiming

Please provide Provide a list of the expenses you are claiming

Upload a quotation or an invoice for each item

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Please check file typePlease provide Upload a quotation or an invoice for each item

Upload a second quote or an invoice for each item

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Upload any other relevant images or documentation such as receipts, invoices, quotes, maps, reports or drawings.

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Has anyone witnessed the event?

Yes
No

Please provide Has anyone witnessed the event?

Full name of witness

Please provide Full name of witness

Witness contact number

Please provide Witness contact number

Were there any other witnesses?

Yes
No

Please provide Were there any other witnesses?

List other witnesses and contact details

Please provide List other witnesses and contact details

Do you need to upload another image or document?

Yes
No

Upload an image or document

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Do you need to upload another image or document?

Yes
No

Upload an image or document

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First name

Please provide First name

Last name

Please provide Last name

Email address

Please provide a valid e-mail addressPlease provide an e-mail address

Postal address

Please provide Postal address

Phone number

Please provide Phone number

Do you give permission to pass on your details and that of your claim for compensation to another agency (such as VicRoads, Barwon Water, the Department of Environment Land, Water and Planning) or third party contractor if we believe it is necessary?

Yes
No

Please provide Do you give permission to pass on your details and that of your claim for compensation to another agency (such as VicRoads, Barwon Water, the Department of Environment Land, Water and Planning) or third party contractor if we believe it is necessary?

You agree

Please provide You agree

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Submit a request for compensation

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Our council

Our services

What’s happening

Submit a request for compensation

Additional uploads

Your details

Other agencies

Declaration

Privacy statement

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