Liability Claim Form

Section 1: Claimant and Incident Details

Title

Full Name

Your email address

Your phone number

Enter your postcode and find your address

Sorry, an address cannot be found

Address

Select address

Address line 1

Address line 2

Address line 3

Address line 4

Country

Postcode

Date of the incident

Time of the incident (12hr or 24hr format)

Please provide a clear summary of the incident

On what date was the issue reported to Welsh Water?

Have you spoken to Welsh Water in relation to this previously?

Yes

Which Welsh Water employee was it reported to?

Please provide details of any witnesses to this incident?

Please provide details and references of any previous contact with Welsh Water relating to this claim

Photograph/Document Upload

Any photographs of the incident location should clearly show the defect and surrounding area. Please mark the exact defect with an ‘X’ and show your direction of travel. If photographs are unavailable, you may wish to use online map services to provide the precise location. The nearest house number or street lamp column would also be of assistance.

File Upload

Would you like to upload more images or documents?

Yes

Additional upload 1

Additional upload 2

Additional upload 3

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Liability Claim Form

Section 1: Claimant and Incident Details

Photograph/Document Upload