Liability claims form

Liability Claim Form

Notice of Injury, Loss or Damage

Purpose of Form: The information disclosed by you in this Claim Form will be used to assess, process and investigate the incident, consider and respond to a claim (including in the course of legal proceedings), to take any necessary remedial action in respect of the incident and for the purpose of risk management activities. We may disclose any information you provide to Council’s insurers and advisers, including investigators and legal advisers

Personal details

Your first name *

Surname *

Preferred contact method *

EmailPhone

Your address

Email address *

Daytime phone *

Mobile phone (if different to daytime phone)

Do you want a Third Party to act on your behalf? If yes, please provide Third Party details below:

YesNo

Third Party first name

Third Party surname

Third Party address

Third Party daytime phone

Third party mobile phone (if different from day time phone)

Are you the person affected by the liability insurance claim?

YesNo

What is the name of the person affected?

Please upload a copy of written authority from the person affected

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Occurrence

What is the type of incident?

Property damagePersonal injury

For property damage claims, please provide TWO repair quotations and/or paid tax invoices

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Property damage claims will only be considered when two quotes are submitted. Please ensure that the quotations are in the name of the person lodging the claim with Council.

Property damage

2 x repair quotations and/or paid tax invoices (mandatory)Any photos of the location of the incident and/or damage sustained. Any further information to support your claim

Personal injury

Personal Injury form 1 (below)Any photos of the location of the incident and/or damage sustained. Any further information to support your claim

Please upload any additional supporting information

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Please fill in the Notice of claim (non-healthcare claims) (form 1) – Personal Injuries Proceedings Act 2002

Date of incident

Time of incident

Have you reported this matter previously?

YesNo

What was the incident reference number?

Please provide details of the incident (specific location, address, site where incident occurred, and any further relevant details)

What is the cause of the incident?

Please provide details of any Council officer you spoke with at the time of the alleged incident. If possible, please include the officer’s name

Alternatively, please supply a Statutory Declaration from an independent third-party witness to the incident

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Please set out the reasons why you believe Council was negligent and liable for your loss, as provided under the Civil Liability Act 2003 (Qld).

Estimate of loss/claim $

Declaration

I confirm that the information provided on this form is true and correct to the best of my knowledge. *

By providing information relating to a request for compensation claim you are confirming that all information is to the best of your knowledge, true and correct and if found not to be, Council reserves the right to refuse or deny a claim.

Privacy statement

Cairns Regional Council is collecting your personal information, including your name, address, email address, and telephone number for the purposes of investigating your complaint. Your information may be shared with investigation officers and with relevant personnel as part of the complaint and investigation process. We will only use your information for this purpose. It will otherwise not be used or disclosed unless authorised or required by law. Your personal information will be handled in accordance with the Information Privacy Act 2009.

Important Information Regarding Claims Against Cairns Regional Council

Please note that Cairns Regional Council (Council) is not automatically liable for a claim because it owns an asset or is responsible for the land on which an asset is located (e.g. potholes, trees). Similarly, Council is not liable for damage resulting directly from weather events (including rain or wind) or other circumstances beyond its control.

If you wish for Council to consider your claim, it is your responsibility to provide sufficient evidence to support it. This includes information that may demonstrate Council has breached its duty to take reasonable precautions against a foreseeable risk of harm, as outlined in section 9 of the Civil Liability Act 2003. Failure to provide sufficient supporting evidence may cause a delay in Council processing the claim.

To establish a finding regarding liability, an investigation will be conducted which will take into account various factors, which include, but are not limited to:

Specific circumstances around the injury, loss and/or damage;
Support evidence provided by the claimant;
Relevant searches of records held by Council;
Consultation with Council’s operational teams; and
Legislation and relevant policies, guidelines and procedures.

Council will assess, investigate and action most claims internally through its Governance Unit; however, in certain circumstances, such as personal injury liability claims or more complex, high value property damage claims, Council may be required to refer these to its insurer.

Please be aware that this notice does not constitute legal advice, and Council does not provide legal advice. Submitting a Claim Form allows Council to assess the information you provide, but it does not initiate legal proceedings.

If Council’s review of your submission indicates that the matter may involve a contractor or third party, you will be advised to contact them directly. Council does not accept liability for losses arising from the actions of contractors or other external parties. Further to this, providing contact details for another party does not imply that Council considers that party is liable.

All properly completed Claim Forms are reviewed, but acceptance of a Claim Form does not mean Council accepts or acknowledges any liability for the matter raised.

Further Assistance

Where necessary, a Council Officer may help you by providing information on how to make a complaint, including how it should be documented. The aim is to help clarify your issue and the outcome(s) you seek.

If you need language assistance, please call the National Translating and Interpreting Service (NTIS) on 131 450. Advise the NTIS of your preferred language and ask to speak with Cairns Regional Council Customer Service on 1300 69 22 47.

If you need assistance because of a hearing or speech impairment, please contact the National Relay Service on 133 677. If you can speak and hear but sometimes people have trouble understanding you, the number to call at the Relay Service is 1300 555 727.