Underground Utility Damage and Reporting for Billing Form
Please provide as much information as possible.
Your name:
*
First Name
Last Name
Your Email:
*
example@example.com
Date damage occurred.
*
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Responsible Party
*
Please Select
NREMC
Contractor
Customer
Location of damage:
*
Street Address or Subdivision
Street Address Line 2
City
State / Province
Postal / Zip Code
Lot #:
Meter #:
Describe the work being performed:
*
Describe what objects were damaged:
*
Describe how the damage occurred:
*
Witnesses:
Use commas to separate names
Employee in-charge:
*
Use commas to separate names
List any other contributing factors:
Was a locate request made?
Yes
No
Were there locates?
Yes
No
Were locates correct?
Yes
No
Were pictures taken?
Yes
No
Were locates requested as emergency or regular?
*
emergency
regular
Requested Date:
-
Month
-
Day
Year
Date
Please upload any pictures or supporting documents.
Browse Files
(You can upload multiple files)
Cancel
of
Your Signature
*
By signing you acknowledge that this information is true should the accident be disputed.
Submit
Should be Empty: