Make an insurance claim | Borough Council of King's Lynn & West Norfolk

Claimant details

Title

If other, please specify

First name

Surname

Date of birth (dd/mm/yyyy)

Occupation (optional)

Postcode

Address name or number

Address line 1

Address line 2 (optional)

Town/Village

County

Phone number

Mobile number (optional)

Email address (optional)

⚠ If you do not provide an email address, we will not be able to send you a confirmation

Representation

Do you have legal representation or an agent?Do you have legal representation or an agent?

Yes

Please provide their details:

Title

If other, please specify

First name

Surname

Relation to claimant (Solicitor/Agent/etc)

Postcode

Address name or number

Address line 1

Address line 2 (optional)

Town/Village

County

Details of the incident

When did the incident happen? (dd/mm/yyyy)

What time did the incident happen? (hh:mm)

Where did it happen? (exact location e.g. house no/street name and town/village)

How did it happen?

Please tell us why you believe the council is legally responsible for your loss

Did anyone else witness your incident?Did anyone else witness your incident?

Yes

Please provide their name and contact details

Title

If other, please specify

First name

Surname

Postcode

Address name or number

Address line 1

Address line 2 (optional)

Town/Village

County

Phone number (optional)

Mobile number (optional)

Email address (optional)

Did you involve the police?Did you involve the police?

Yes

Police incident number (optional)

Police station

Postcode (optional)

Address name or number (optional)

Address line 1 (optional)

Address line 2 (optional)

Town/Village (optional)

County (optional)

Other information relating to the incident

Did you notify the council of the incident?Did you notify the council of the incident?

Yes

If you have any receipts, photographs or quotes relating to the incident, then these can be provided later in the form

Who did you notify within the council?

Title

If other, please specify

Name (full name if known)

Department (if known) (optional)

When did you inform the council? (dd/mm/yyyy)

Property damage

If the incident involved a defect, did you notify the Council before your incident?If the incident involved a defect, did you notify the Council before your incident?

Yes

Who did you notify within the council?

Title

If other, please specify

Name (full name if known)

Department (if known) (optional)

When did you notify the council? (dd/mm/yyyy)

Please remember to attach any receipts and/or repair estimates with this form. Also please be sure to include the vehicle make, model and registration number if your vehicle was damaged.

Description of item(s) lost/damage

Estimated cost to repair or clean

Your insurer's details

Are you claiming damage to a vehicle or property?Are you claiming damage to a vehicle or property?

Yes

Insurer's name

Claim number (optional)

Policy number

Postcode (optional)

Address name or number (optional)

Address line 1 (optional)

Address line 2 (optional)

Town/Village (optional)

County (optional)

Injury

Are you claiming for an injury?Are you claiming for an injury?

Yes

If you suffered an injury as a result of the incident, the council and it's claims and legal agents have a duty to advise the Department of Work and Pensions (Compensation Recovery Unit) that you have submitted a claim for compensation. To ensure we only pass on the correct information, you must provide all the relevent information requested.

National Insurance Number

Description of injuries resulting from the incident

Doctor's details

Title

If other, please specify

First name

Surname

Hospital/Clinic/Surgery

Town

Did you consult your doctor about these injuries or attend hospital after the incident?Did you consult your doctor about these injuries or attend hospital after the incident?

Yes

Please tell us where you attended and the name of the Doctor / Clinician who treated you

Title

If other, please specify

First name

Surname

Postcode

Address name or number

Address line 1

Address line 2 (optional)

Town/Village

County

Are you still receiving treatment?Are you still receiving treatment?

Yes

Please provide details

Employment

Are you employed?Are you employed?

Yes

Employer name

Employer phone number

Employer email address (optional)

Employee number (optional)

Contact title

If other, please specify

Contact first name

Contact surname

Postcode

Address name or number

Address line 1

Address line 2 (optional)

Town/Village

County

Please list any dates of absence

Date of absence 1

Date absent (dd/mm/yyyy) (optional)

Evidence

Please upload any evidence you have to support your claim (image or documents) (optional)

⚠ Please upload one file at a time and wait until the file has 100% uploaded each time

Privacy Notice

The Council has a duty to process and store your personal information safely and securely in line with data protection legislation, which here means the General Data Protection Regulations (Regulation (EC) 2016/679 which is in force from 25 May 2018) (GDPR) and any national implementing laws, regulations and secondary legislation, as amended or updated from time to time, in the UK and then any successor legislation to the GDPR.

The Borough Council of King’s Lynn and West Norfolk (the Council), of Kings Court, Chapel Street, King’s Lynn, Norfolk, PE30 1EX is the data controller for the purposes of the GDPR and associated domestic law.

We will use your personal information for the purposes of the provision of Insurance claims. The processing of this information is necessary for the Council to undertake a public task, i.e. the processing is necessary for the Council to perform a task in the public interest or for its official functions.

Your data will be used for this specific purpose and will be passed to Zurich Municipal (our insurer) who are contracted to undertake the insurance claim on behalf of the Council. It may also be shared between Council departments and other agencies where there is lawful authority to do so.

Your information will be kept strictly confidential. It will be stored separately from other information in a secure, password-protected database on the Council’s computer system.

Your personal information will be kept for as long as the details are required. You can find more information about our retention policy on the privacy notice page. We will only use your data within the terms of data protection laws, will delete your data securely and only keep it for as long as necessary. We will review dates for keeping personal data in the future and if necessary update these privacy notices.

You may see copies of the data held about you and ask for it to be corrected or deleted.

You can find more information about Data Protection and the Council's Data Protection Officer, on our Data Protection page.

If you are unhappy with the way your personal information is being handled you can contact the Independent Information Commissioner.

Declaration

Please ensure you read our Information Pack before submitting the form.

Have you read the Information Pack?

Yes

Terms

I certify that I have read, understand and accept the information and terms provided by the Borough Council of King’s Lynn and West Norfolk

I agree

Declaration

Please read this declaration carefully before you press submit.

I certify to the best of my knowledge and belief, the information supplied by me on this form is accurate and true.
I understand that any alleged loss that is found to have been fraudulent, falsely stated or exaggerated will be passed to the Police and may be subject to criminal prosecution.
I understand the personal information collected on this form will be used by the Borough Council of King's Lynn and West Norfolk to process my claim and will be retained securely.
I understand the personal information will be disclosed to other agencies, including our insurer Zurich Municipal (or any future insurer), in connection with processing this claim and identifying potential cases of fraud. This includes periodic data matching exercises such as the National Fraud Initiative.
I understand that the information provided on this form is subject to the provisions of the General Data Protection Regulations (Regulation (EC) 2016/679 which is in force from 25 May 2018) (GDPR) and the Data Protection Act.

You can find out more detailed information about our Privacy Policy, on our privacy notice page.

I confirm that all of the details I have provided are correct and I understand that the information provided on this form is subject to the provisions of the above privacy notice

I agree