utilities injury/accident report form
Report of Personal Injury or Damage to Property
(for use of all Utilities except Railroads, Street Railroads and Motor Carriers)
Instructions: In the event of more than more person being involved in the same accident, fill out a separate form for each person. Submit this report to the Commission within ten days of the date of the accident.
* Additional information, photographs, sketch of accident, emergency responder reports, etc. in support of this notification may be emailed to firstname.lastname@example.org.
PLEASE FILL OUT ALL APPLICABLE FIELDS