Claim Forms

To file a claim, you will register, then complete the claim form or forms that apply to the type of claim or claims you are making from the claim types listed below. You can complete the forms on our website. You can also download printable claim forms (using Adobe Acrobat) to complete and mail in.

Get started by clicking on one of the claim forms below. Have more questions? Read our FAQ.

RESIDENTIAL

If you lived in a house, condo, or apartment that received tap water from West Virginia American’s Kanawha Valley Water Treatment Plant on January 9, 2014 your Household is  eligible to make a claim for a Residential Household payment.  Renters are eligible too even if you didn’t pay your own water bill.

BUSINESS

Businesses and nonprofit entities that were being served tap water by West Virginia American’s Kanawha Valley Water Treatment Plant on January 9, 2014 are eligible to make a claim for a Business payment using one of the two types of Claim Forms below.

WAGE EARNER

If you were employed by a business that was shut down due to the Freedom Chemical Spill and you were paid on an hourly basis, then you are eligible to make a claim for lost hourly wages during the shut down using the Wage Earner Individual Review Claim Form. To be eligible for a payment, you must provide certain documents that show your wage loss.

MEDICAL

Residents who went to the ER, doctor’s office, urgent care or hospital because they believed they may have been harmed by the contamination or disruption of the water supply are eligible to make a claim for medical costs and for payments relating to specific injuries caused by the Freedom Chemical Spill.

PREGNANT

Women who were pregnant on January 9, 2014 and exposed to the contaminated water while living in an eligible residential household can make a claim for a payment of $1,500.

GOVERNMENT

Municipal and county government entities that lost tax revenue and faced extraordinary expenses and that were being served tap water by West Virginia American’s Kanawha Valley Water Treatment Plant on January 9, 2014 are eligible to make a Governmental claim.

Already started a form? Login to complete or submit form