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
- No
Mailing Address*
Street Address City State ZIP Code
Property Damaged
Date of Damage*
Date Format: MM slash DD slash YYYY
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
List All Witnesses
Name
Phone
Address
Street Address City State ZIP Code
Would you like to add an additional witness?
- Yes
- No
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.
Date*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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