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Notice of Claim

This form is to be used for a property damage or personal injury claim only. For billing inquiries, please call 353-2222.

Contact Information

CPS Energy Account Number:

* Best phone number:

* First name:

Alternative phone number:

* Last name:

* Email:

* Mailing Address Line 1:

Mailing Address Line 2:

(Apartment, Suite, Trailer, Lot, Unit, etc.)

* City:

* State:

* Zip Code:

Claim Information

* Type of Damage:

Property Type (If applicable):

* Date of Loss:

Total claim amount: $

Police Report number: (If applicable)

* Loss Location (Street Address):

* Claims description for Property Damage or Personal Injury:

1500 character(s) remaining.

Attachments (photos of damage, documentation, diagrams, etc):
Allowed Extensions: .jpg, .jpeg, .bmp, .gif, .png, .doc, .docx, .pdf, .ppt, .pps, .xls, .xlm, .rtf, .pptx

Agreement

By checking this box, I , state that the information contained in this statement is true and accurate to the best of my knowledge. Willfully submitting false or inaccurate information will result in your claim being denied.

Sign Date:

Notice of Claim

Electric Outage Reporting