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