Claims For Damage

Lewis County PUD uses reasonable diligence to furnish uninterrupted service, but shall not be liable for any interruptions caused by strikes and/ or other labor disputes, accidents or acts of God, or by any cause beyond the control of the District, or by the necessity for making repairs or changes in Lewis County PUD’s equipment and facilities as noted in the Electrical Service Application and Contract.

If you believe that the damage to persons and/or property resulted because of negligence of Lewis County PUD or its employees, please complete and submit the form below. A negligence-based investigation will be conducted, and you will be informed of the results.

Lewis County PUD’s Executive Assistant serves as its primary Claims Agent to receive all claims for damages and the Auditor serves as the backup Agent.

"*" indicates required fields

ATTENTION: Your claim will be considered only when this report is properly completed AND estimates of the cost of repairs or receipted bill is attached. Once the completed Claim Form is returned to the PUD, an investigation will be completed and you will be notified of the findings.

Claimant's Information

Claimant's Name*

First Last

Phone Number*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Do you have a different mailing address you would like to list?*

Yes

Mailing Address*

Street Address City State ZIP Code

Property Damaged

Date of Damage*

Approximate Time of Damage*

Hour

Minute

Describe Property Damaged*

Location Where Damage Occurred*

Estimated Cost of Repairs / Replacement

Describe in Detail What Happened*

Attach additional information as required, including relevant receipts or estimates of repairs*

Drop files here or

Max. file size: 30 MB.

List All Witnesses

Name

Phone

Address

Street Address City State ZIP Code

Would you like to add an additional witness?

Yes

Additional Witness Name

Additional Witness Phone

Additional Witness Address

Street Address City State ZIP Code

Acknowledgment

Type Your Full Legal Name to Acknowledge & Agree the Terms Listed Above*

I hereby verify the information provided on this form to be true and complete. I understand that by typing my full name above and submitting this information, this form will be stamped with today’s date and authorized by me as if I had signed my signature. I certify under penalty of perjury of the state of Washington that I am the individual named in the above electronic signature block.

Hidden

Date*

This field is for validation purposes and should be left unchanged.

If you have questions regarding the claim process, please contact by Email.

Claims For Damage

Claimant's Information

Property Damaged

List All Witnesses

Acknowledgment

Call

fax

Visit

Mail

Call

fax

Visit

Mail