Forms

These forms are filed with and approved by the Ohio Department of Insurance:

Coverage form:

OMSIUA Coverage Form (OH-MSI-2)

Two-part offer and application for optional counties:

Offer of Mine Subsidence Insurance Form (OH-MSI-1)

Application Form (OH-MSI-3)

Combined offer and application for optional counties (may be used in lieu of the above):

Offer and Application Form (OH-MSI-4)

*Click here for instructions for this form.