Rate Adjustment Request Form – Greater Johnstown Water Authority

Rate Adjustment Request

ACCOUNT NUMBER*
(required field)
NAME*
(required field)
Email*
(required field)
STREET ADDRESS*
(required field)
CITY, STATE, ZIP*
(required field)
DAYTIME PHONE NUMBER*
(required field)
Explain where and how the water loss occurred.*
(required field)
Date(s) of Water Loss*
(required field)
Is the account occupied or vacant?*
(required field)
- OCCUPIED
- VACANT
Do you have insurance on the property?*
(required field)
- YES
- NO
Name of Insurance Company*
(required field)
Policy Number*
(required field)
Agent's Name*
(required field)
Agent's Address*
(required field)
Agent's Phone Number*
(required field)
Has a claim been filed with your insurance company?*
(required field)
- YES
- NO
Are repairs complete?*
(required field)
- YES
- NO
Repair Bill
If you have a repair bill, use 1 of 3 ways to get it to us:
1) Upload a photo or scan using this form.

2) Mail to:
    Greater Johnstown Water Authority
    PO Box 1407
    Johnstown, PA 15907-1407

3) Drop off a paper copy at our offices:
    640 Franklin Street
    Johnstown, PA 15901
Repair Bill File Upload
Accepted file types: jpg, png, gif, pdf.
AS STATED IN THE GREATER JOHNSTOWN WATER AUTHORITY RATES, RULES AND REGULATIONS, THIS TYPE OF BILLING ADJUSTMENT IS ONLY ALLOWABLE ONE TIME. IF GRANTED, A FEE OF $100.00 WILL BE CHARGED AND INCLUDED IN THE FINAL ADJUSTMENT FIGURE. NO FEE WILL BE IMPOSED IF THE ADJUSTEMENT IS DENIED.
Verification*
(required field)
- I hereby verify that the statements made herein are true and correct to the best of my knowledge, information and belief. I further acknowledge and understand that statements herein are punishable as a misdemeanor under the Pennsylvania Crimes Code, 18 Pa. C.S.A. Section 4904, relating to unsworn falsifications to authorities.Checking this verification checkbox and submitting this form constitutes my consent for the GJWA to contact my insurance carrier.
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Rate Adjustment Request

Repair Bill