WRC Basement Flooding Claim (PA 222)

Save my progress and resume later | Resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Confirm Password:

Password must contain the following:

12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character

Claim Information

An individual who has been injured or who has suffered property damage as a result of a sewage disposal or stormwater system event must provide written notice of the event within 45 days after the date the damage or injury was discovered, or in exercise of reasonable diligence, should have been discovered. Failure to provide proper written notice within 45 days will bar your claim.

To make a claim for damages or physical injury arising from a sewage disposal or stormwater system event, please provide the following information:

First Name

Last Name

Phone

Address

City

State

Zip Code

Is this the address of the affected property?

YesNo

Enter the address of the affected property

City

State

Zip Code

Do you claim property damage?

YesNo

Do you claim personal injuries?

YesNo

Do you have a Sump Pump?

YesNo

Where does your sump pump discharge?

Sanitary Sewer Storm SewerUnknownPrivate Property (i.e. French Drain)

Date of discovery of property damages or physical injuries

State law requires that you notify this office in writing within 45 days after the damage was discovered or should have been discovered or your claim will be barred.

Please briefly describe what happened:

Property Damage Summary

Description	Cost of item
	$
	$
	$
	$
	$
	$

What is the total cost of the property damage?

Property Ownership Information

Do you own or are you in the process of buying your home?

YesNo

Are you a tenant paying rent for your home?

YesNo

Landlord's First Name

Landlord's Last Name

Landlord's Address

City

State

Zip Code

Insurance Information

Name of your insurance company

Insurance policy number

Name of your insurance agent

Phone number for your insurance agent

Have you filed a claim with your insurance company?

YesNo

Please explain your reason for not filing:

Insurance claim number

Has the insurance company paid any portion of your claim?

YesNo

How much was paid?

If the insurance company denied your claim, what was the reason provided?

Property Damage Document Check List

To assist the investigation of your claim, we will ask you to provide legible copies of the following items:

Declaration Page of your Homeowner’s Insurance Policy showing your deductible.
Clear photos of property damage.
Receipts for damaged items / or repairs made.
Proof of submission to insurance company along with payment or denial correspondence.

1. Declaration Page

Attach the Declaration Page of your Homeowner’s Insurance Policy showing your deductible.

2. Photos

Attach clear photos of property damage.

If you prefer to submit video documentation of the property damage, email video to wrc@oakgov.com. Please include the street number, street name and city/village/township of the backup in the subject line.

3. Receipts

Attach photos of receipts for damaged items / or repairs made.

4. Insurance Correspondence

Proof of submission to insurance company along with payment or denial correspondence.

Submission

This form is being provided to assist the property owner in submitting a claim and does not constitute an admission of liability or other representation as to the merit of the claim, or that the property owner is entitled to reimbursement for damages.

Save my progress and resume later | Resume a previously saved form