State Form 54909 (R2 / 2-14)

Note: The person completing this form should only complete information known by that individual when completing the request.

Case Number:

Who is submitting this form?

Date of Damage (month, day, year):
/ /

Location of Damage

Address (number and street):



ZIP Code:

Nearest Intersection:

Excavator Information

Business Name:

Responsible Party Personal Name:

Title (if any):

Address (number and street):



ZIP Code:

Preferred Telephone Number (area code):

Email Address:

Utility Information

Utility Name:

Contact Person:

Title (if any):

Product Type:

Facility Type:

Facility Depth(Inches):

Interruption in Service: Yes No

Number of Customers Affected:

Evacuation: Yes No

If yes, how many evacuated?:

Cause of Damage Information

Type of Equipment:

Type of Work Performed:

Repair Cost: $

Did a leak result from damage: Yes No

Was there ignition: Yes No

Excavator Notify 911 due to leak: Yes No

Excavator Notify 811 upon damage: Yes No

Excavator Notify Utility upon Damage: Yes No

Locate Information

Excavator Request Locate: Yes No

Indiana 811 Locate Ticket Number:

Locate Marks Visible: Yes No

Locate Marks Correct: Yes No

Excavator "White Lined": Yes No

Was Locate Provided within Two Working Days: Yes No

Utility Employees On-site during Excavation: Yes No

Incident Information

Fire Department Response: Yes No

Police Department Response: Yes No

Ambulance Response: Yes No

Circumstances that may increase/decrease severity of damage event:

Additional Information / Comments:

Printed Name:

Signature: *If submitting this form electronically, typing your name in the signature box will act as an electronic signature.

Date (month, day, year):
/ /

If you would like a copy of this form for your records, please print the completed form before submitting it.

Or mail to:
Indiana Utility Regulatory Commission
Pipeline Safety Division - Case Number
101 West Washington Street, 1500E
Indianapolis, IN 46204
Or fax to: 317-233-2410