General Information Member CompaniesAgent Forms

The forms included in this section are for the benefit of any person working with the Ohio Mine Subsidence Insurance Underwriting Association (OMSIUA). Agents, adjusters, or the Insureds can print these forms for use.

The Application Form is for optional counties where a property owner may desire coverage. Please complete the form in detail and return same to the agent and then on to the company with the application premium.

The Offer of Mine Subsidence Insurance Form is for anyone in an optional county. It should be read prior to completing an application.

The Claim Notice Form can be used in place of the electronic notice contained in this web site. It may be printed and filled out (as completely as possible). It can then be faxed or mailed with a copy of the claimant's current declaration page (showing coverage in force) directly to the OMSIUA Claim Department.