Utility Break Reporting

Underground Utility Break Reporting
Reporting Date*

MonthDayYear
Date
Name of person filing this report:*

First NameLast Name
Supervisor*

Chris PettisCody ZimmermanEric OdonelKris GardnerJoe PerezJosh DiGulioPaul SchaiderMichael KovalSean SesherZach McCoyOther
Chris Pettis Projects
Cody Zimmerman Projects
Eric O' Donel Projects
Joe Perez Projects
Josh DiGulio Projects
Kris Gardner Projects
Michael Koval Projects
Paul Schaider Projects
Sean Sesher Projects
Zach McCoy Projects
Other Project (jobs that do not appear in the drop down menu above)
Date of the Incident*

MonthDayYear
Date
Time of the Incident*

:HourMinutesAM/PM Option
Select the employees that were involved in the incident:*
Other Employees on-site
Other people (non-employees) that were involved in the incident
General Contractor/Customer*
Address (or closest address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Was the damaged line marked?*

YesNo
Was the area around the damaged line "white lined?"*

YesNo
What is the One Call Transmittal #?*
If unkown, type "unknown." If a locate was not called in, type "N/A."
What is the date of the last update for the Transmittal?

MonthDayYear
Date
Was the damaged utility line shown on the plans and/or drawings?

YesNo
What type of line was damaged (i.e. natural gas, fiber, water, phone, electrical)?*
What size is the damaged line?*
Equipment that was involved in the incident*
Who was operating when the line was hit?*
Employee's Description of the incident*
Job Task at the time of the incident*
Where any steps taken to identify or locate unmarked utilities (i.e. hand digging, hydro-excavation, probing, ground penetrating radar, etc.)?*
Name of Utility Company?
Name of Utility Company representative?
Utility Company representative phone #?

Area CodePhone Number
Did the Utility Company Representative make any statements? If so, what?
Arrival time for Utility Company's "repair crew."

:HourMinutesAM/PM Option
Departure time for Utility Company's "repair crew."

:HourMinutesAM/PM Option
What was the size of the utility company's crew that responded?
Please provide a list men and equipment.
What is the transmittal number for the "Dig Up Ticket"?
Pictures

Please include photos. If you have more than 6 photos that need to be filed with this claim, please email them direct to Carter at: carter@pfeifferandson.com.
Pre-work photo (i.e. showing marking before excavation began).
Pre-work photo (i.e. showing marking before excavation began).
Pre-work photo (i.e. showing marking before excavation began).
Post-damage photo.
Post-damage photo.
Post-damage photo.
Signatures
Employee Signature*

Clear
Should be Empty:

Underground Utility Break Reporting

Pictures

Signatures