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 sbintz@utah.gov.

 

PLEASE FILL OUT ALL APPLICABLE FIELDS

Submittal Date:
Name of Utility:
Address:
City, State, Zip Code:
 
Name of person injured or owner of property damaged:
Street Address:
City, State, Zip Code:
Date & Time of Property Damage or Accident:
Exact Location of Property Damage or Accident:
 
INJURY OR DEATH
Person Involved: Employee
Contract Employee
Non-Employee
Accident: Injury
Death
Age:
Gender:
Nature and Extent of Injury:
Cause and Manner of Accident:
 
PROPERTY DAMAGED
Property Damaged - Utility Property: Yes
No
Describe the Damages:
Approximate Amount of Damages:
How did damage occur:
 
Can you suggest a practical method of guarding against a repetition of this accident? Yes
No
If yes, what suggestions would you make?
 
Witness to accident:
Street Address:
City, State, Zip Code:
Telephone Number:
 
CONTACT INFORMATION
Person responsible for submitting this report:
Title:
Telephone Number:
Email Address:
 
Supplemental Notes/Comments:

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