Claim Submission Form

Notice of Collection

Personal information contained on this form is collected under the authority of Part II of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. M.56 and Section 11 of the Municipal Act, 2001, S.O. 2001, c. 25.

The information is used to receive, review, investigate (including contacting and following up with claimants), as well as determining eligibility with respect to and resolving (including the contesting of the validity of) claims made against the County of Prince Edward (including but not limited to written notice of a claim, details of the occurrence, and injury complained of). Information may be shared with municipal departments, various agents, consultants, experts, and other third parties retained by the municipality based on the allegations made in the claim, or to undertake work or provide services in relation to the purposes noted above, as the municipality determines is appropriate. Questions about this collection can be directed to the Clerk’s Office, County of Prince Edward, 332 Picton Main Street, Picton, ON K0K 2T0 or by email clerks@pecounty.on.ca.

Claims Submission Form

A claimant is the person or business who suffered the damage or injury.
Name*
Email*
Phone*
Mobile Phone
Street*
City*
Province*
Postal Code*
Please note: The County of Prince Edward does not maintain Loyalist Parkway from the Glenora Ferry to 12690 Loyalist Parkway and Loyalist Parkway from Cold Storage Road to 30 Bloomfield Main Street or Highway 62 (entire length from Bay Bridge to Bloomfield Sign). Please contact the Ontario Ministry of Transportation for information on those roads.
Date of Loss*
Incident address or coordinates with nearest intersection*
Incident description*
Please provide a brief description of the damage or injury that occurred. This claim may be submitted to the municipality's third-party insurance adjustor who may contact you. Please upload any documentation you wish to provide with your claim in .jpg or .pdf format. Missing information will cause delays in the processing of your claim. To submit additional information in support of your claim, please email claims@pecounty.on.ca as soon as possible. In the event that your claim is accepted, an invoice is required.
Optional: Please upload any additional attachments, if necessary
Example: photos
Max. file size: 128 MB.

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Notice of Collection

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