Ohio Turnpike and Infrastructure Commission

682 Prospect St

Berea, OH, 44017

Phone: (440) 234-2081

www.ohioturnpike.org

Serving the nation - The James W. Shocknessy Ohio Turnpike

Please answer all the following questions.

This form will ask you to provide information about your car insurance policy, please have that information on hand before beginning this form.

Please note that filling out this form does not guarantee a reimbursement.

Contact information: Contact Information

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Vehicle Make:

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Contact information: Contact Information

Insurance Policy Provider

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Insurance Policy Coverage Dates

Insurance Agent Phone Number

Certificate of Insurance

Do you have an E-ZPass Account?

Vehicle Make:

Vehicle Model:

Vehicle Year:

Vehicle Color:

Repair Invoice

Date of Incident:

Time of Incident:

Location of Incident:

OSHP Crash Report Number (if Applicable):

OSHP Crash Report

Description of Damage

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