Test Accident Form

Report of Personal Injury or Damage to Property
(for use by all Utilities except Railroads, Street Railroads and Motor Carriers)

Instructions: In the event of more than one person being involved in the same accident, fill out a separate form for each person. Submit this report to the Public Service 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 psc@utah.gov

Injury / Accident Form


Utility Address:

Contact information for the person submitting the form:


If yes, please continue:

Address of Property Damaged:

If yes, Please continue:


If yes, Please continue: