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:
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:
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 forsubmitting this report:
Title:
Telephone Number:
Email Address:
Supplemental Notes/Comments: (Not Required)