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.



Injury / Accident Form

INJURY OR DEATH

PROPERTY DAMAGED

WITNESS

CONTACT INFORMATION