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INCIDENT QUESTIONNAIRE

Isle of Wight Council

INCIDENT QUESTIONNAIRE

Complete this form to notify the Council of personal injury or damage to property.

Important Information for Pothole Claimants

Although you have hit a pothole on a road owned by the Isle of Wight Council, it does not mean you are entitled to compensation.

Potholes can break out very quickly and it is simply not possible for the Isle of Wight Council to check every road on the Isle of Wight every day.

The law recognises this and therefore the legal requirement for local councils is to check each road for defects monthly, quarterly or annually depending on the type of road and its usage.

Therefore if we have inspected the road within the timescale, and the pothole was not present on the date of inspection then we have complied with the law.

If a pothole has broken out since this inspection, it does not mean the Isle of Wight Council is negligent.

Please bear this in mind when making a claim.

Notes

Please read the following information before completing this form.

Data Protection Statement

The details provided by you will be held on a database and used for the purposes of investigating your claim and may be shared with or passed on to other Council departments or outside agencies who may be involved in a potential claim, as well as the Councils Insurers or legal representatives so that a formal response to your comments can be made. The Isle of Wight Council is the data controller for the purposes of the Data Protection Act 1998. Please note the information collected may be accessed by virtue of the Freedom of Information Act 2000 or by yourself under the Data Protection Act 1998.

Anti Fraud Statement

The Authority is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes.

For further information, see web-link to the Level 2 notice on the Isle of Wight Councils website. The web address is www.iwight.com/nfi.

Insurance fraud is a criminal offence. Persons who make fraudulent or exaggerated claims are liable to prosecution.

Liability

The provision of this form does not constitute an admission of liability on behalf of the Isle of Wight Council.

What happens to my claim?

Upon receipt, the Councils Insurance Section will work together with the appropriate department, complete an investigation and pass all relevant documentation to the Councils Insurers who will then correspond with you or your legal representative. There is no automatic right to compensation and claims are paid on a strict liability basis. A claim for compensation can be made in person or through a legal representative.

Section A: Claim Details (must be completed)

If you are completing this form on behalf of the claimant please state your name & relationship here:

Claimant Details:

	Title
*	Forename
	Middle name/Initials
*	Surname

*	Building/house name/number
*	Street address
*	Town Name
	County
*	Postcode

	Tel Number (include area code)
*	Occupation
	Email address

Please note: Details of your date of birth and national insurance number must be given if you have suffered injury

*	Date of Birth	dd/mm/yyyy
*	National Insurance Number

Particulars of Incident

*	Date	dd/mm/yyyy
*	Time	: (24hr clock)
*	Road Name
*	Town

Full description of incident including exact location (i.e. house numbers, landmarks)

If you are printing your form, please attach a sketch plan of the location and any photographs in support of your claim to this form and send them to the address on the final page. If you are submitting the form online, please email your supporting documents to [email protected]

If so, then please provide their name and address as we may wish to approach them for a statement:

	Witness One
	Witness Two

You may be contacted to attend a site meeting at the location where the incident occurred. If the Authority does so, you are entitled to bring an Independent Person or Legal Advisor with you.

	Section B
	Please only complete if your incident involved your motor vehicle if not go to Section C

Vehicle Registration

Make

Model

Please state the traffic conditions on the day in question

Light

Moderate

Heavy

Please state the speed of your vehicle immediately before impact with the defect

Did you see the defect before you hit it?

Yes

If yes, what was the distance between you and the defect?

What action did you take?

Have the police any report of the incident?

Yes

If yes, please provide the name and number of the officer and their station together with the crime reference number

	Please attach a copy of the vehicle's Insurance certificate with this form AND if your vehicle is more than 3 years old please attach a copy of your MOT certificate also. PLEASE NOTE both certificates must be valid on the date of the incident
	If you are printing this form and sending it in by post or bringing it into the council in person, please attach a copy of the vehicle's Insurance certificate. If you are choosing to submit the form online, please send or email a copy of the vehicle's Insurance certificate to the address shown on the final page. If your vehicle is more than 3 years old please attach a copy of your MOT certificate to this form or send it in to the same address accordingly.

Section C: Declaration

Any other comments that you would like to make

I have read and agree with the Data Protection and anti fraud statements. I confirm that the information supplied on this form is true and correct to the best of my knowledge and belief.

Please tick this box (if not signing) to indicate you understand and accept the requirements and conditions for this application

Signature

Signed ...............................................................................

Name.................................................................................

Date...................................................................................

Have you included your insurance certificate and MOT certificate
(if applicable)?

Please return this form along with any other supportive documentation to:

Insurance Section,
County Hall,
Newport,
Isle of Wight
PO30 1UD

Or by email to: [email protected]

Please note that by law the Isle of Wight Council's insurer has 90 days to respond to you with a view on liability.

Data Protection Act 1998

This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request.

The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy. Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest.

Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law.

Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box

To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box

Date printed: 07/03/2013

	INCIDENT QUESTIONNAIRE
	Complete this form to notify the Council of personal injury or damage to property.
	Important Information for Pothole Claimants
	Although you have hit a pothole on a road owned by the Isle of Wight Council, it does not mean you are entitled to compensation. Potholes can break out very quickly and it is simply not possible for the Isle of Wight Council to check every road on the Isle of Wight every day. The law recognises this and therefore the legal requirement for local councils is to check each road for defects monthly, quarterly or annually depending on the type of road and its usage. Therefore if we have inspected the road within the timescale, and the pothole was not present on the date of inspection then we have complied with the law. If a pothole has broken out since this inspection, it does not mean the Isle of Wight Council is negligent. Please bear this in mind when making a claim.

	Notes
	Please read the following information before completing this form.
	Data Protection Statement The details provided by you will be held on a database and used for the purposes of investigating your claim and may be shared with or passed on to other Council departments or outside agencies who may be involved in a potential claim, as well as the Councils Insurers or legal representatives so that a formal response to your comments can be made. The Isle of Wight Council is the data controller for the purposes of the Data Protection Act 1998. Please note the information collected may be accessed by virtue of the Freedom of Information Act 2000 or by yourself under the Data Protection Act 1998. Anti Fraud Statement The Authority is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes. For further information, see web-link to the Level 2 notice on the Isle of Wight Councils website. The web address is www.iwight.com/nfi. Insurance fraud is a criminal offence. Persons who make fraudulent or exaggerated claims are liable to prosecution. Liability The provision of this form does not constitute an admission of liability on behalf of the Isle of Wight Council. What happens to my claim? Upon receipt, the Councils Insurance Section will work together with the appropriate department, complete an investigation and pass all relevant documentation to the Councils Insurers who will then correspond with you or your legal representative. There is no automatic right to compensation and claims are paid on a strict liability basis. A claim for compensation can be made in person or through a legal representative.