Notice of Claim Form

Making a Claim Against Local Government
Any comments or actions by the local government in response to your complaint are strictly without prejudice. In other words, comments made to you by staff or representatives of the local government are not to be taken as an admission of liability or as confirmation of any cause of action you might have. Similarly, by submitting this form, you are not waiving any of your rights.

Below is an excerpt from the Local Government Act explaining why you must provide written notice of your claim within two months of suffering the loss. Your phone call or visit to the Municipal Hall does not constitute notice under the Act unless notice of your intention to claim is also provided in writing.

Immunity unless notice given to municipality after damage

736 (1) A municipality or regional district is in no case liable for damages unless notice in writing, setting out the time, place and manner in which the damage has been sustained, is delivered to the municipality or regional district, as applicable, within 2 months from the date on which the damage was sustained.

(2) In case of the death of a person injured, failure to give notice required by this section is not a bar to the maintenance of the action.

(3) Failure to give the notice required by this section or its insufficiency is not a bar to the maintenance of an action if the court before whom it is tried, or, in case of appeal, the Court of Appeal, believes

(a) there was reasonable excuse, and

(b) the defendant has not been prejudiced in its defence by the failure or insufficiency.

There are other limitation periods that apply to your claim and you might wish to consult with legal counsel. The information contained herein does not take the place of legal advice.

Notice of Claim
Notice of claim provided to:

The Corporation of the City of White Rock
Attention: Administration Department
15322 Buena Vista Avenue
White Rock BC V4B 1Y6

This letter is intended to provide notice to the above local government pursuant to section 736 of the Local Government Act of my intention to bring a claim against it for the following:
Select one(s) apply:*

damage to my property and/orinjury to my person
The particulars of my claim are as follows:
Claimant's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone number*
Email address*
example@example.com
Date and Time of loss*

MonthDayYear
Date
Hour MinutesAM/PM Option
Nature of damage or injury (include value of claim, if known)
Reason why you feel the local government is at fault
Cause of the damage or injury and exact location (describe hazard or event)
If you are submitting this form more than two months from the date of loss, please explain the reason for the delay
Additional information (e.g. photographs of any property damage, if applicable)

File must be smaller than 5MB in PDF or JPG format.
Cancelof
Electronic Signature Agreement
By selecting "I agree", you are signing this form electronically and you agree your electronic signature is the legal equivalent of your manual signature on this form.*

I agree
Electronic Signature*
Personal information contained on this form is collected under the Freedom of Information and Protection of Privacy Act and will be used only for the purpose of responding to your request.
Today's Date

YearMonthDay
Please verify that you are human*
Should be Empty:

Notice of claim provided to: