Notice of Claim Form

First Name

Last Name

Street Address

City/Town

Province/State

Postal Code/ZIP

Country

This form allows you to save a draft. An email with a link to your draft will be sent to the address provided above upon the draft’s first save. Subsequent saves will not resend this email. Upon submission, you’ll receive a second email confirming the final values provided.

Daytime Phone Number

Alternate Phone Number

Are you also submitting this claim on behalf of anyone else?

Who are you submitting this claim on behalf of?

Please Provide Their Name

First

Middle

Last

Address/Location of the Incident

Date/Time of the Incident

Type of Incident

Please Specify the Type of Damage

Please Specify the Type of Injury

Details of the Incident

Loss/Damages Resulting From the Incident

Do you have any supporting documents to attach to this claim?

I.e. receipts, photos or additional documents.

Supporting Documents

Please include any receipts for the cost of repair damage.

Your last name must be in the file name of all uploads.

E.g. Smith Receipt.jpg

If you have additional photos or documentation, please email them directly to clerks@mapleridge.ca. In the subject line please include:

Additional Claim Documents: LastName, First Name - Original Claim Submission Date

E.g. Additional Claim Documents: Doe, John - June 8th, 2024

Maximum 3 files.
5 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

I confirm that by checking the box below, I have read and understand this Notice of Claim form in its entirety and I understand that:

Per section 736 of the Local Government Act, notice of a claim must be provided to the City within two (2) months of the date on which the damage was sustained;
There may be other limitation periods that apply to this claim;
The written notice must set out the time, place, and manner in which the damage was sustained;
Submission of a claim does not guarantee any compensation for damages as compensation is based solely on the City insurer’s determination of the City’s liability;
Any comments or statements made by the City of Maple Ridge, including City staff, does not constitute admission of liability or as confirmation of any cause of action you may have for this claim;
This information is not legal advice and you should consult legal counsel if you wish to obtain legal advice; and
The information provided above is accurate to the best of my knowledge

I Understand

Disclaimer

Any comments or actions by the City of Maple Ridge in response to your complaint are strictly without prejudice. Similarly, by submitting this form, you are not waiving any of your rights. Note that a phone call or visit to the Municipal Hall does not constitute notice of claim under the Local Government Act unless notice of your intention to claim is also provided in writing.

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Personal information entered on this form is collected under the authority of section 26(c) of the Freedom of Information and Protection of Privacy Act (FOIPPA) for the purposes of processing your input. If you have any questions or concerns about how your information will be used, contact the FOI Office by calling 604-466-4300 or by emailing FOI@MapleRidge.ca. For more information about FOIPPA at the city, please visit our Freedom of Information page.