2. Claimant Information
   Notice: Information contained in this document may be disclosed to Charleston Water System (CWS) officials, associates, and General Counsel and their staff involved in the processing of your claim.
4. First Name*
5. Last Name*
7. Email*
8. Daytime Phone*
9. Fax
11. Address*
13. Address
15. City*
16. State*
17. Zip*
19. Are you a Charleston Water System customer?*

    1. Yes
    2. No
21. Please provide your CWS account number
23. Description of Claim
    Please provide a description of the claim you are making against Charleston Water System. The acceptance of this claim by Charleston Water System does not constitute an admission of legal liability on the part of CWS or any of its departments. Failure to provide adequate information may result in your claim being returned or denied.
25. Type of claim *

    Select all that apply.

    1. Personal injury
    2. Property damage from water
    3. Property damage from sewer
    4. Automobile damage
    5. Other (please specify below)
27. Other
29. Date and time of incident*
    Date and time of incident

    Date and time of incident
31. Description*
    Please describe the injury or damages. If medical attention was provided, provide the names and addresses of treating medical providers and medical reports and billings.
33. Was this incident reported to law enforcement, safety or security personnel?*

    If yes, please provide a copy of the incident report in the next section.

    1. Yes
    2. No
35. Was CWS notified of any potential risk?*

    1. Yes
    2. No
37. When and to whom?
39. Exact location of incident*
    Please be specific, providing any intersections or notable landmarks.
41. Please list anyone else involved in or witness to this incident*
    Please provide the names, addresses, and telephone numbers of all persons involved in or witness to this incident.
43. Dollar amount claimed
    Please provide copies of any paid receipts or estimates in the next section.
45. Supporting Documents
47. Do you have any supporting documents, such as cost estimates, receipts, photos, an incident report, etc?

    1. Yes
    2. No
48. How would you prefer to submit supporting documents?

    1. Upload them from my computer and submit electronically with this form
    2. Provide hard copies by mail, fax, or hand delivery
    3. Separately via email
50. Please list the supporting documents you will be providing

    Below are instructions for how to submit your supporting documents.

    
    

    You will have the option to print this form and receive an email copy with this information.

    
    

    Attn: Tort Damage Claims

    
    

    Mail

    Charleston Water System

    Attn: Damage Claims

    PO Box B

    Charleston, SC 29403

    
    

    Email

    damageclaims@charlestoncpw.com

    
    

    Fax

    (843) 579-6744

    
    

    Hand Delivery

    103 St. Philip Street

    Charleston, SC 29403

52. Supporting document 1
54. Supporting document 2
56. Supporting document 3
58. Supporting document 4
60. I declare under penalty of perjury under the laws of South Carolina that the foregoing is true and correct.*

    1. I agree
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

* indicates a required field