Report a Claim for Damages

Claimant Information
Name*

First NameLast Name
Email*
Home Phone*
Please enter a valid phone number.
Work Phone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Incident Information
Date of Occurance*

MonthDayYear
Date
Time of Occurance*

Hour Minutes

AM/PM Option
Type of Incident*

WaterSewerAutoPersonal InjuryOther
Address of Occurrence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Description of Damages*
Estimated Costs*
Prior Incidents
For a line break, are you aware of any other line breaks in the vicinty?*

YesNo
If yes, give the date, location, and description of break:
Witnesses

Add witness names here and attach any witness statements in the File Upload section, if available.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add another contact?

Yes
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add another contact?

Yes
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add another contact?

Yes
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Owner Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurer Information

Notice: Your carrier must be notified as required by PA law (42 Pa.C.S.A. §8553)
Is the property insured?*

YesNo
Was the carrier notified?*

YesNo
Company*
Policy Number*
Agent*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
File Upload

You must submit documentation to support your claim, such as photos, videos, witness statements, estimates, invoices, receipts, and homeowner’s, automobile, and renter’s insurance documentation. Please note that Pittsburgh Water will not return any items submitted as part of a claim. Please keep duplicates for your records.
If your files are above the upload size limit, please email them to claims@pgh2o.com along with your name and a note explaining which claim they are for.
Cancelof
Any person who knowingly and with intent to injure or defraud any insurer, files an application or claim containing any false, incomplete, or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine up to $15,000.00.
Signature*

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Signature Date*

MonthDayYear
Date
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Claimant Information

Incident Information

Prior Incidents

Witnesses

Property Owner Information

Insurer Information

File Upload