Claimant’s report of injury or damage Date __________________________
Claim # (if known) ________________
Owner of property damaged ________________________________________ Phone _________________________
Address ________________________________________________________________________________________
_______________________________________________________________ Police report # __________________
Date of accident ____________ Time of accident ________
a.m. p.m. Location _______________________
Witnesses
Name _________________________________________
Address _______________________________________
Phone ________________________________________
Name __________________________________________
Address ________________________________________
Phone _________________________________________
Was anyone injured?
Yes No If yes, list name(s): ____________________________________________
Describe injury: __________________________________________________________________________________
Was property damaged?
Yes No
If yes, list and/or describe damages: _________________________________________________________________
Estimated value or cost to repair (if known) $ _____________
Was a vehicle damaged?
Yes No
Vehicle make ____________________ Vehicle model ___________________ Vehicle year ____________________
Describe how the injury/damage happened:
Date of report __________________________ Reported by ____________________________________________
Return to: Peoples Gas Company – Attention: Claim Services
• Mail: 200 East Randolph Street, Chicago, Illinois 60601
• Fax: 312-240-4370
• Email: Claims@peoplesgasdelivery.com
Questions: Call 866-227-2941
