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Claim Information Form

  1. 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.

  2. Address or landmark required

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

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

  5. Leave This Blank:

  6. This field is not part of the form submission.