Reference to Courts Clause Samples

Reference to Courts. Any constitutional issue arising out of, or in respect to, this Agreement or the matters implemented or settled by this Agreement, and any dispute relating to the interpretation or administration of this Agreement or the use or administration of Trust Funds, other than for the use of Trust Funds for the payment of Claims as described in articles 5.0 and 6.0, shall be referred to court and not decided by a Claims Officer or an Appeal Claims Officer under articles 5.0 or 6.0.  Name:  Address:  City/Town:  Commercial Fishing Licence (if applicable):  Commercial Trapping Licence No. (if applicable):  Band Name and Number (if applicable): DETAILS OF CLAIM  Date & Time of Injury/Loss/Damage:  Activity at time of Injury/Loss/Damage:  Cause of Injury/Loss/Damage:  Compensation Claimed:  Nature of Injury:  Goods or Property Lost or Damaged: o General Description: o Make: o Model: o Serial No.: o Year Manufactured: o Year Purchased: o Purchase Price: o Location where Injury/Loss/Damage occurred (Attach Sketch or Map): o Names of Witnesses to Injury/Loss/Damage:  Is the Claim covered by insurance in whole or in part: Yes? No? o If yes, give particulars: o If yes, has a claim been made under the insurance policy? Yes? No? o Give particulars: I hereby consent to my insurer releasing information about my insurance policy and insurance coverage relating to the injury/loss/damage that is the subject of my Claim to the Claims Officer who is responsible for assessing my Claim. (Signature of Claimant) (date)