Details This form should be completed and forwarded to: Horsham Rural City Council Risk Management Co-ordinator PO Box 511 Horsham Victoria 3402 For any queries on the completion of this form: Please contact Horsham Rural City Council on Ph (03) 5382 9777 Email: Please tick boxes where appropriate Please select the compensation sought: Property Damage Personal Injury Motor Vehicle Other Contact Details Mr Mrs Ms Miss Title: Full Name: Address: State: Post Code: Email: Ph No: Mobile No: Incident Information Date: Time: Weather and Road Conditions (if (applicable) e.g. raining, sunny, dark, dry, wet etc. – Location Address: Nearest Intersection: Distance to Intersection (m/km): List any road infrastructure or other infrastructure involved, if applicable (traffic lights, signs, fences, poles, pit lids, etc.) Description of Incident
Details This form should be completed and forwarded to: Horsham Rural City Council Risk Management Co-ordinator PO Box 511 Horsham Victoria 3402 For any queries on the completion of this form: Please contact Horsham Rural City Council on Ph (03) 5382 9777 Email: Please tick boxes where appropriate Please select the compensation sought: Property Damage Personal Injury Motor Vehicle Other Contact Details Title: Mr Mrs Ms Miss Full Name: Address: State: Post Code: Email: Ph No: Mobile No: Incident Information Date: Time: Weather and Road Conditions (if (applicable) – e.g. raining, sunny, dark, dry, wet etc. Location Address: Nearest Intersection: Distance to Intersection (m/km): List any road infrastructure or other infrastructure involved, if applicable (traffic lights, signs, fences, poles, pit lids, etc.) Description of Incident
request_for_compensation_form.docx