Required fields are marked with asterisks (*)

Statement of Damage Claim Form

For completion by a party claiming the municipality is at fault for damages to their property.

Claimant Information

Incident Information

Please be specific referencing direction of travel, lane and closest intersection/reference point OR upload a diagram/map if needed below.


Allowed extensions pdf, doc, docx, jpg, jpeg, gif, png, tif

Witness Info

Please use the below buttons to add witnesses to the incident

I solemnly swear that I am the owner/occupier of the property damaged, that the foregoing is a correct and accurate statement as to the damages incurred and that I have no insurance or warranty of any type under which such damages may be recoverable.


Please note: This statement is for information purposes only and its receipt in no way infers acceptance of any responsibility by this Municipality for the stated damages. A fully completed and signed form is to be send to the County address above by mail, e-mail or fax upon which you should receive a written confirmation acknowledging your claim receipt within 30 days time. Be aware that there are notice periods for providing the County with notice of certain types of claims and limitation periods with respect to all claims. If you do not commence legal action to advance your claim within two years of the date of the incident cause loss or damage, the County of Grande Prairie and its employees will be entitled to immunity from liability in respect of your claim pursuant to the provisions of the Limitations Act of Alberta. 

This personal information is collected un the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act and will be used to process claims against the County. It may also be disclosed to third parties to verify the information given. It is protected by the privacy provisions of the Act. If you have any questions about the collection, use or disclosure, contact the Risk Management and Insurance Coordinator at 780-532-9722.