PSC Injury and Accident Report Form

General Information

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

Form Submittal Date *

Utility Name *

Utility Address

Street *

City *

State *

Zip Code *

Contact Information of the Person Submitting Form

Name *

Title *

Phone (XXX-XXX-XXXX) *

Email *

Supplemental Notes and Comments

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