Property Damage Report - Formstack

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Property Damage Report

Name of employee involved in incident*

First Name

Last Name

Job Title of employee involved in incident*

Miller Pipeline Job Number

Date and Time of Incident*

:

Street Address of Incident*

City of Incident*

State of Incident*

Has the property owner been notified of the damage?*

Yes No

Name of Property Owner

Address of the Property Owner

Address Line 1

Address Line 2

City

State

ZIP Code

Phone Number of Property Owner

What type of property was damaged?*

Please Specify:

What type of equipment was involved in the incident?*

Please Specify:

Describe the event in detail (be specific: include all persons involved, sequence of events, measurements, etc.)*

Were pictures of the damage taken?*

Yes No

Optional Attach File (Photo or Scanned Document)

No File Chosen

File uploads may not work on some mobile devices.

Examples may include: photos, invoices, estimates, other documentation

Optional Attach File (Photo or Scanned Document)

No File Chosen

File uploads may not work on some mobile devices.

Examples may include: photos, invoices, estimates, other documentation

Optional Attach File (Photo or Scanned Document)

No File Chosen

File uploads may not work on some mobile devices.

Examples may include: photos, invoices, estimates, other documentation

Optional Attach File (Photo or Scanned Document)

No File Chosen

File uploads may not work on some mobile devices.

Examples may include: photos, invoices, estimates, other documentation

Optional Attach File (Photo or Scanned Document)

No File Chosen

File uploads may not work on some mobile devices.

Examples may include: photos, invoices, estimates, other documentation

Name of Superintendent*

First Name

Last Name

Name of Foreman*

First Name

Last Name

Which division do you work in, Gas Construction or MSD?*

Name of Miller Pipeline Customer*

Send a copy of this form to the following email address:

Send a copy of this form to the following email address:

Send a copy of this form to the following email address: