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Account Information

Description of Incident

AM or PM *
Type of Work Being Done
Work Performed By

If police responded, attach a copy of the police report or enter the name of the responding agency and the report number.

Repair Estimates

Attach a copy of any repair estimates you have received or enter any repair information.

Witness(s) to the Incident

Was KUB notified at the time of the incident?
AM or PM

I certify that all the statements contained herein and on any attachments hereto are true and that the injuries and/or damages reported were actually incurred. I also acknowledge that it is a misdemeanor to file a false claim with Knoxville Utilities Board and/or the City of Knoxville and I understand that any claim will be evaluated by KUB pursuant to the terms and practices of the Government Tort Liability Act TCA 29-20-101 et seq.