UniSource Statement of Damage

UniSource Statement of Damage
If you believe UniSource is financially responsible for damage to your property, please complete and submit this “Statement of Damage” form. If UniSource accepts responsibility for your claim, the company will determine what the law considers fair compensation and reimburse the lowest of repair costs, replacement costs or fair market value. UniSource is not liable for indirect, or consequential damages including lost revenue or profits.
Date of Submission

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Incident Information
Date/Time of Incident*

MonthDayYear
Date
Hour MinutesAM/PM Option
Service Address*
Type of Claim*

Auto IncidentDisconnection of ServicesMeter ExchangePower OutagePower SurgeProperty DamageOther
Please describe what happened. Be as detailed as possible.*
Damaged Item*
Original Cost*

$0 – $100$101 – $500$501 – $5,000$5,001 – $25,000Over $25,000
Age of Damaged Item
Is the item repairable?*

YesNo
Estimated Cost to Repair
Actual Cost (Must Include Receipt)
Upload Supporting Documents (Receipts, Pictures, Estimates, Etc.)

Cancelof
Additional Remarks
Signature*
Printed name will serve as electronic signature
You may voluntarily provide the personal information required to complete this form. UniSource Energy Services uses this information to fulfill the purpose for which it was obtained. To find out more about the categories of personal information UniSource collects and the purposes for which such information will be used, please refer to our Privacy Policy.
Please verify that you are human*
Should be Empty:

UniSource Statement of Damage

Incident Information