CLAIM FORM
This form is to be completed by a person claiming that Ontario Northland is responsible for damage to their property or for bodily injury suffered by them or an affiliated person.
Instructions
: Provide as much information as possible, including any supporting documentation, to allow Ontario Northland to evaluate your claim.
Claimant Information
Collection and Use of Personal Information
: The personal information contained in this form is being collected pursuant to the
Ontario Northland Transportation Commission Act
and will be used by Ontario Northland to process your property damage or bodily injury claim. Questions about this collection should be directed to: Privacy Officer, 555 Oak Street East, North Bay, ON, P1B 8L3, (705) 472-4500,
accessandprivacy@ontarionorthland.ca
.
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First and Last Name
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Address
Street
City
Province
Postal Code
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Contact Info
Telephone #
Email
Incident Details
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Date and Time of Incident
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Location of Incident
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Type of Damage
Bodily Injury
Real Property
Personal Property - Vehicle
Personal Property - Baggage/Lost or Stolen Items
Personal Property - Express Freight Shipment/Auto Carrier
Other
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Description of Property Damage or Bodily Injury
Describe what happened as well as the extent of the damages or injuries that you sustained and state why you believe Ontario Northland should be responsible for those damages or injuries.
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Value of Claim
Indicate the amount of money that you are claiming from Ontario Northland.
Supporting Documentation
Upload any photos, invoices, receipts, or other evidence that you have to support your claim.
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Was the damage or injury reported to Ontario Northland?
Yes
No
Who was the damage or injury first reported to and when (date/time)?
Witness Information
Enter the names and phone numbers of all witnesses involved, if known.
Name of Witness/Relationship
Witness Telephone #
Declaration & Disclaimer
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Declaration
I declare that I am the owner/occupier of the property damaged and/or the person, or the representative of the person, who suffered bodily injury and that the foregoing is a true and accurate statement of the damages or injuries sustained.
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Disclaimer
I acknowledge that this claim form is for information purposes only and its receipt by Ontario Northland is not an admission of liability by Ontario Northland for the property damage or bodily injury sustained.
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Signature
Date