Damage Claim Report
Your Name:
Your Cell #:
Damage Address:
City:
County:
State: ZIP:
Down Claim Number:
Client Name:
Damage Date / Time:
 : am pm
Date Reported / Time:
 : am pm
Arrival On Site Date / Time:
 : am pm
Investigation Completed:
 : am pm
 
Description
of Damage:
Damager Statement:
Comments Made OnSite:
Commentator's Full Name: Phone #:
 
Damage Location Type:
Activity Type:
Damaged By:
Facility Type:
Other:
Motor Veh.
Power Exc.
Sewer Exc.
Street Exc.
Telephone
Water Exc.
Unknown
Grader
Motor Veh.
Shovel
Tractor
Trencher
N/A
Unknown
Buried Service
Pole
Utility Vault
Pedestal/Closure/AP Box
Other:
 
If Railroad then Right of Way Owner: UPRR CSX BNSF FEC CN KC South
 
Damager Information Insurance Company Information
Bill This Address:
Company Name:
Contact's Name:
Address:
City:
State: ZIP:
Phone #:
Bill This Address:
Insurance Company:
Policy Number:
Address:
City:
State: ZIP:
Phone #:
 
Locate Information
Bill This Address:
Company Name:
Address:
City:
State: ZIP:
Phone #:
Locate Ticket #:
Dig Start Date:
Time:
 : am pm
Locate Company Claim #:
Locate Detail:
Print Info:
Markings:
Other Utilities Located:
Incomplete Locates
No Locate Requested
Premature Dig
Records Error
 
If Multiple Please Explain:
Permanent Markers
 
Police Dept. or Hazmat Information
 Witness Statement / Information
Responding Officer:
Jurisdiction:
Case #:
Phone #:
Full Name:
Company:
Address:
City:
State: ZIP:
Phone #:
Statement
 
Aerial / Underground Cable Information
Cable Size: # of Fibers Damaged: Depth at Damage:
Was Damage Exposed? Pole Replaced?  
Cable Attached to The Cable the Street the Highway the Alley
Height of Vehicle: feet inches Height of Attachment: feet inches
 
TCC Investigator - OnSite Investigation Notes:
Provide FACTUAL statements and conclusions as a result of your investigation (include such things as what you saw, heard, observed, etc.)
Photos Taken? . . Yes . . . . No
Name of Person Taking Photos:
Video Taken? . . Yes . . . . No
Name of Person Taking Video:

Sketch Area: Take the photo(s) / video(s) of your sketch and upload with the damage investigation photo(s) / video(s) using the below link:




JNR Home JNR About Us JNR Login