Damage and Loss Claim Form

Important – please read before submitting a claim

This form is for persons wishing to claim for damages or loss they believe to be the result of the negligent actions or omissions of Main Roads Western Australia and/or its contractors.

Please note the following before you proceed:
  • Personal injury claims: If you believe you have suffered substantial personal injury, do not complete this form. Instead, we suggest you seek independent legal advice, as strict time limits may apply.
     
  • Claims outside Main Roads’ scope: If your claim falls outside the matters managed by Main Roads, we may provide the details you submit (including your contact information and claim form) to the relevant Local or State Government body or other third-party service provider so that your matter can be dealt with by the appropriate organisation.
By submitting this form, the personal information you provide will be collected and stored by Main Roads Western Australia to assess and manage your claim.

Your information may be shared within Main Roads or with relevant third parties where necessary to assess or respond to your claim.

If you do not provide the requested information, Main Roads may be unable to assess or progress your claim.

You can find more information about how we handle personal information in our Privacy Policy on our website.

To request access to your personal information, or to lodge a privacy complaint, please contact us at privacy@mainroads.wa.gov.au.

By continuing, you confirm you have read and understood this notice.
 
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 (cost estimate, numbers only)*
 
 
 
 
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 you are unable to submit, please check the form is complete.