Damage Report Form

 
1 Start 2 Complete
Instructions
Please report damage below. Fields with red asterisks are required.
Please enter your name.
Please list street number, street name and zip code of location of damage
If the repair is urgent (can't wait two weeks), please describe the urgency: Wedding on Saturday, Can't get mail, etc.
If you have already discussed this damage with the office or a foreman, please let us know the details of that interaction.
What is your current relationship with WideOpen?
Is there anything else you would like us to know?
Please upload images of damage
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png avi mov mp3.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Image CAPTCHA
Enter the characters shown in the image.