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Claim Information Form

2. Please complete the form as thoroughly as possible. You will be notified by mail of the date and time of your claim hearing. You are not required to attend, but may do so if you wish. Claim hearings are held at the Law Department. Please call 419-221-5161 with any questions.

   Please complete the form as thoroughly as possible. You will be notified by mail of the date and time of your claim hearing. You are not required to attend, but may do so if you wish. Claim hearings are held at the Law Department. Please call 419-221-5161 with any questions.

4. First Name*

5. Last Name*

7. Address1*

9. Address2

11. City*

12. State*

13. Zip*

15. Email

16. Phone Number

18. Date of Occurrence*

19. Time

20. Amount of Damage Claimed*

22. Location*

    Address or landmark required

24. Description of Damage*

    Please be as specific as possible. Be sure to include how the damage occurred.

26. Upload photos, repair estimates, etc.

28. Insurance Information

    Please list the company name, your policy number, and the deductible amount.

Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit Submit and Print

* indicates a required field