File a Claim - Ohio Mine Subsidence

OMSI Claims Procedure

To Report a Claim

A claim can be reported via:

The form below
Faxing information to 614-839-1468

A copy of the property owner's declaration page should be submitted with the claim. Please call 614-823-6008 for claims emergencies.

Property Claim Notice

* denotes required fields

Insured Name & Address

First Name:

Last Name:

Address:

City

State:

* Zip Code: -*

Phone:

--* Ext. Type: *

Property Address

Property address different than insured address

Property Address:

City:

State:

* Zip Code: -*

Contact Information

Contact same as Insured

First Name:

Last Name:

Phone:

--* Ext. Type: *

Email:

Loss Information

Date of Loss:

* (mm/dd/yyyy)

Agency Information

Name:

Email:

Insurance Company Information

Company Name:

Reported By

Name:

Phone:

--* Ext. Type: *

Email:

Description of Loss*

Documentation

Please attach a copy of the insured's declaration page and any other documentation to support this claim. You may attach as many files as you wish, but they must be attached one at a time.

Note: Each attachment must be smaller than 4 megabytes and must be in one of the following formats:

JPG, JPEG
GIF
TIF, TIFF
BMP
PDF
DOC, DOCX

Joint Photographic Experts Group
Graphic Interchange Format
Tagged Image File Format
Bitmap
Portable Document Format
Microsoft Word Document

Attached Files:

(No Files Attached)


	Click the "Browse" button to select a file you would like to attach to this application. After you have selected a file, click the "Attach File" link to attach the file you selected to this application.

Attachment Location:

	Attach File