Incident Investigation/Claim Form

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If you believe that your injury, vehicle or personal property damage was a result of an incident involving a water main break, sewer back-up or work performed by the Western Virginia Water Authority, please complete this Incident Investigation/Claim Form below. 

Fully complete this form and submit online  or  download the form and e-mail it to risk.management@westernvawater.org

You can request a paper copy be sent to you by contacting 540.283.2964 or e-mailing to risk.management@westernvawater.org. Completed forms should be mailed to Western Virginia Water Authority (Attn: Risk Management) 601 S Jefferson Street, Suite 210, Roanoke, VA 24011

Be sure to fill the entire form and include any information that will assist us with investigating your claim, such as repair receipt(s), photos of your damage, plumber’s statement/receipt, if appropriate; police report, if appropriate;  medical bills and/or medical reports, if appropriate. 

For Cleanout reimbursements please send inquiries to Sewer@westernvawater.org

 

Upon completion of this form, please click Submit.  An auto-generated response will be displayed below once your form has been submitted.  The form will automatically be forwarded to the Western Virginia Water Authority's Risk Management Division. 


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