N1 East UEP Incident Report

Note: Any person who, with the intent to injure, defraud. or deceive any insurer. self-insurer or self-insurance fund. presents orcauses to be presented any written or oral statement concerning a claim, knowing that such statement contains false, incomplete or misleading information concerning any fact or thing material to such claim. may be prosecuted for a felony pursuant to Section 817.234, Florida Statutes, and, if found guilty, can be subject to substantial criminal and civil penalties.

Please complete and sign this information report providing details regarding the damage to your property, suppling as much information as you have such as date, times, location, how it happened, as well as any documentation you may have to assist with the review of your claim, such as police report, photos and quote/invoices for repairs.

The contractor has 30-days from date of receipt to respond to you.

Name

First NameLast Name

Property Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone #: Home/Work

Please enter a valid phone number.Format: (000) 000-0000.

Phone #: Cell

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Date and Time of Incident/Damage:

Date

Hour Minutes

AM/PM Option

Exact Location(s) of Incident/Damage:

(please be sure to include crossroads/intersections if applicable)

In your own words please describe details of the Incident/Damage:

By signing this form, I/we give the contractor for the North 1 East UEP project and/or their representative permission to inspect my property.

I designate _____________________________ (North 1 East UEP contractor) to allow access to my property.

Signature

Date

Please check if would like to submit attachments with this report.

Please check the attachments that are included with report:

Please upload attachments here:

Additional details:

You may also submit this report or additional information by one of the following:

Email: info@N1EastUEP.com

or

Mail: City of Cape Coral North 1 East Utilities Extension Project

c/o CMA Outreach, Inc. - 3860 Colonial Blvd., Ste 201, Fort Myers, FL 33966

If you should have any questions, please contact us at (833) CAPE UEP - (833) 227-3837

For office use only: Date received:

NORTH 1 EAST UEP INFORMATION REPORT