Master Incident Report

Master Incident Report

If you need to report a vehicle accident, please call Fleet Response at 1-800-338-0619

If you have any questions or suggested improvements to this form, please contact Greg Greene at 317-260-3705 or gregory.greene@millerpipeline.com

Question 1

Was anyone injured?*

Yes No

Injury Reporting

Who was injured? (Check all that apply)*

Miller Employee Non-Miller Employee

For the Miller employee who was injured, please contact the Miller Pipeline Injury Reporting Hotline at 1-855-MPL-OUCH

Name of Person Injured (Non-Miller Employee)

First Name

Last Name

Address of Person Injured (Non-Miller Employee)

Address Line 1

Address Line 2

City

State

ZIP Code

Phone Number of Injured Person (Non-Miller Employee)

Describe the incident in detail (be specific, include names of those involved, sequence of events, measurements, working conditions, etc)*

Any witnesses to the incident (include contact numbers)

Question 2

Was there a vehicle accident?*

Yes No

Vehicle Accident Reporting

Which vehicle(s) were involved in the accident?

Miller Pipeline Vehicle (owned or rented) and Non-Miller Pipeline Vehicle Miller Pipeline Vehicle only (either owned or rented) Non-Miller Pipeline Vehicle only

Please contact Fleet Response at 1-800-338-0619

Incident Log

Describe the incident in detail (be specific, include names of those involved, sequence of events, measurements, working conditions, etc)*

List all items taken or damaged. Make sure to include make/model, description, and estimated value for each item you list.

Asset number(s) of any Miller-owned equipment that was involved in the incident

Question 3

Was there damage, or alleged damage, to a utility? (May include things like: gas line, electric line, water, sewer, telephone, cable, fiber, etc)*

Yes No

Question 4

Was there damage, or alleged damage, to property? (May included things like: landscaping, sprinklers, mailboxes, home exterior/interior, etc.)*

Yes No

Property Damage Reporting

Name of Property Owner

First Name

Last Name

Address of Property Owner

Address Line 1

Address Line 2

City

State

ZIP Code

Phone Number of Property Owner

Has the Property Owner been notified of the damgage?

Yes No

What type of property was damaged?

Please specify*

Damaged Vehicle Make

Damaged Vehicle Model

Damaged Vehicle License Plate #

Damaged Vehicle Insurance Carrier

Damaged Vehicle Insurance Carrier - Policy Number

Damaged Vehicle VIN

Describe the incident in detail (be specific, include names of those involved, sequence of events, measurements, working conditions, etc) *

Description of the Property Damage

Question 5

Was there theft of or damage to Miller Pipeline property, equipment, vehicles, etc?

Yes No

Describe the incident in detail (be specific, include names of those involved, sequence of events, measurements, working conditions, etc)*

List all items taken or damaged. Make sure to include make/model, description, and estimated value for each item you list.

Asset number(s) of any Miller-owned equipment that was involved in the incident

Notification Details

Name of Superintendent*

First Name

Last Name

Name of General Foreman

First Name

Last Name

Name of Foreman*

First Name

Last Name

Send a copy of this form to this email address:

Confirm Send a copy of this form to this email address: *

firstname.lastname@millerpipeline.com (can only send to Miller Pipeline employees)

Send a copy of this form to this email address:

Confirm Send a copy of this form to this email address: *

firstname.lastname@millerpipeline.com (can only send to Miller Pipeline employees)

Send a copy of this form to this email address:

Confirm Send a copy of this form to this email address: *

firstname.lastname@millerpipeline.com (can only send to Miller Pipeline employees)

Once you hit the "Submit" button, please make sure to close your internet browser to ensure the form does not submit twice.

If you have any questions on this form, please contact Michelle Hall (317.653.5286)

Question 1

Injury Reporting

Question 2

Vehicle Accident Reporting

Incident Log

Question 3

Utility Damage Reporting

Question 4

Property Damage Reporting

Question 5

Additional Details

Notification Details