Customer / Caller Information

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* 1. Customer / Caller Information

Nature of Incident: (Select all that applies.)

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* 2. Nature of Incident: (Select all that applies.)

Does outage cover an entire block or Single Address?

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* 3. Does outage cover an entire block or Single Address?

Please Select Utility Provider.

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* 4. Please Select Utility Provider.

Other Comments / Remarks

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* 5. Other Comments / Remarks

If appropriate, please include an image of incident.

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* 6. If appropriate, please include an image of incident.

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