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-36-120 (Penalties) Please ensure all claim information provided

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Job ____________________________ Title: ____________________________________
Full
Address: ________________________________________________________________
City: __________________________ State: _____ Zip: _____
______
Primary Phone:______________________________ Secondary Phone: __________________________
Email:
Alternate email address
Please provide the most accurate option from the list regarding which stakeholder group you represent?
Initiated Stakeholder:
If investigator selected, please provide name and contact info of the authorized operator who approved submission
Name:
Phone: Email:
Please provide the most accurate option from the list regarding which stakeholder group you are filing a claim against?
Accused Stakeholder: SC License#:
If investigator selected, please provide name and contact info of the authorized operator who approved submission
Name:
Phone: Email:
Select the type of law violation that best represents this claim from the list?
Violation:
If you chose non-member of SC811 please ensure you have verified from the SC811 Member list (link to our website)
Have you or your company previously submitted a claim against the accused company?
If yes, please provide date claim was filed and/or the claim number associated.
If the accused was a contract excavato
r please provide SC license number
Information can be found at LLR.SC.gov
Section 58
-36-120 (Penalties)
Any person who violates any provision of this chapter shall be subject to a civil penalty not to exceed one thousand
dollars for each violation. Actions to recover the p
enalty provided for in this section shall be brought by the
Attorney General at the request of the injured party in the proper forum in and for the cou
nty in which the cause, or
some p
art thereof, arose or in which the defendant has its principal place of business or resides. All penalties
recovered in any such actions shall be equally divided between the state’s general fund and the Office of the
Attorney General.
Submitting a Damage Claim to the Attorney General
Please ensure all claim information provided on this form is accurate prior to sending. The Attorney General will
review and resp
ond to all enforcement DFWLRQVXQGHUWKH8QGHUJURXQG'DPDJH3UHYHQWLRQ$FWȕ-36-120 taken in
South Carolina. If you want to submit a damage claim to the Attorney General for review
and a decision with regard to
enforcement by th
e Attorney General, please fill out the form below and email it to SC811@scag.gov and
Enforcement@SC811.com
6&is in no way invo
lved in making decisions or actions regarding this process. We only facilitate a mechanism
for the complaint forms and tracking of where claims are in the process. 3OHDVHGRQRWFRQWDFW6&LI you have
any questions about the status of any potential action by the Attorney General. If you have any questions, please
contact the Attorn
ey General’s office directly at the above referenced email address. &ODLPVDUHQRWFRQILGHQWLDO
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Damage Claims Form for Submission to the Attorney
General
Name:
Company:
Select One
Select One
Select One
Select One
Select
Please list names and contact information for any other involved parties, to include the owner of the damaged
facilities; all contractors and subcontractors involved in the excavation that led to the damage; the owner of the project
that gave rise to excavation project. (If more space is needed, use additional pages.) :
Please address why this matter should be address by the Attorney General. (Typically, this would involve multiple
incidents in which the same person was at fault. Reports to the Attorney General requesting criminal charge should
only be made in extraordinary circumstances.) (If more space is needed, use additional page.)
***Please provide photos of the incident, including damaged facilities, equipment used and markings; the costs of
the repairs if any have been made; an estimate of the cost of repair if one is available; a copy of the SC811 ticket
and any responses; maps of the area; any
other helpful information about this incident. ***
By signing this document, I state that all of the information I have provided is true to the best of my knowledge.
Date of Incident:
Description of Incident (If more space is needed, use additional pages.):
Was a locate notice created ZLWK6&
for this location/project?
If yes, please provide Tick
et Number
Was there a damage associated with this incident?
If so, what was the amount of damage?
If a utility was damaged, please select the type of excavation that resulted in the damage?
Was this
incident associated to a pipeline damage?
Location of Incident:
Time of Incident:
(If possible, SOHDVHLQFOXGHPDSVRQDVHSDUDWHSDJH
Was the fire department notified?
Select
Select
Select
Select One
full physical address including zip code
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-36-120 (Penalties) Please ensure all claim information provided

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Completed 27 September 2021

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