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. Amount of claim……………………………………………………………………………………... Name of Claimant…………………………………………………………………………………… Address………………………………………………………………………………………………. ………………………………………………………………………………………………………… Telephone…………………………………………………………………………………………..... E-mail…………………………………………………………………………………………………. Time and Date of Incident………………………………………………………………………….. Specific location of Incident ……………………………………………………………………….. (please state nearest side street or intersection) ………………………………………………………………………………………………………… Direction of Travel…………………………………………………………………………………… Do you believe there still to be a hazard at this location? ...................................................... Do you have comprehensive insurance cover? …………………………………………………. If Yes to above, which company? .......................................................................................... Have you lodged a claim for this damage or loss with your insurance company?............................................................................................................................... Invoice for repairs or quote showing estimated cost of repairs (please select one option below) are provided or will be provided Main Roads Western Australia P O Box 6202, EAST PERTH WA 6892 Telephone 138 138 Facsimile: (08) 9323 4598 E-mail: [email protected] MAIN ROADS Western Australia D13#38363 Nature of incident and details of damage – Overleaf (Include supporting documents or include extra pages as necessary) ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… Main Roads Western Australia P O Box 6202, EAST PERTH WA 6892 Telephone 138 138 Facsimile: (08) 9323 4598 E-mail: [email protected] MAIN ROADS Western Australia D13#38363 Page 2
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