Damage and Loss Claim Form

Note: this form is to be used by persons wishing to claim for damages or loss they believe to be the result of the negligent actions or omissions of Main Roads and/or its contractors. If you believe you have sustained personal injuries as a result of this incident, you should not complete this form. You should seek independent legal advice as time limits may apply. 

 
Details of person/s submitting Claim
 
 
First name*
 
 
 
 
Last name*
 
 
 
 
Email*
 
 
Phone*
 
 
 
 
Street Address*
 
 
 
 
Suburb *
 
 
 
 
Postcode *
 
 
 
 
 
 
 
Details of incident / claim
 
 
 
 
 
Date of incident (DD/MM/YYYY)*
 
 
 
 
Direction of travel
 
 
 
 
Road weather conditions
 
 
 
 
Visibility
 
 
 
 
Road name/specific location of incident*
 
 
 
 
Nearest side street/intersection
 
 
 
 
Amount of claim (estimate)*
 
 
 
 
Describe the type of property damage
 
 
 
 
 
 
 
Other information- hazard report / insurance
 
 
Have you reported the hazard / problem to Main Roads previously?
 
 
 
 
If yes please enter your fault / case reference below
 
 
 
 
 
 
 
Have you or do you intend to lodge a claim with your insurer, or does this claim relate to an insurance company?*
 
 
 
 
(Insurance) If yes, which company
 
 
 
 
Description of incident*
 
 
 
 
By selecting the yes option below I declare the information provided on this form is true and correct to the best of my knowledge.*
 
 
 
 
 
 
 
 All the required (*) fields must be completed before you can submit this Damage and Loss Claim Form.  If your unable to submit please check the form is complete.