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INCIDENT NEAR <br /> MISS AND LOSS REPORT <br /> (HSE 1 AUTO 1 PROPERTY) <br /> Stantec <br /> Com fete on! i incident involves a vehicle owned leased or rented boy Stantec <br /> SECTION 3 -AUTOMOBILE LOSS <br /> r. STANTEC VEHICLE <br /> Year Make Model VIN <br /> Mileage <br /> License Plate No. &Province/State <br /> Present location of vehicle Use at time of accident <br /> r.. <br /> STANTEC DRIVER <br /> Name Date of Birth Operator License. No. & Province/State <br /> �.. Na. Years Driving No.Years Driving for Stantec <br /> DESCRIPTION AND ESTIMATE OF DAMAGES <br /> V <br /> DAMAGE TO OTHER VEHICLES (Attach separate page if necessary) <br /> VEHICLE#1 VEHICLE#2 <br /> Owner Name Phone Owner Name Phone <br /> Address Address <br /> ____[ <br /> +V <br /> Year, Make&Model of vehicle License Plate No. Year, Make&Model of vehicle JLicense Plate No. <br /> Name of Insurer Name of Insurer <br /> �.. Policy No. Policy No. <br /> Description of damage Description of damage <br /> V <br /> Name of Driver(if different from owner) Name of Driver(if different from owner) <br /> Address(if different from owner) Address(if different from owner) <br /> Phone Operator License. No. & Province/State Phone Operator License. No. &Province/State- <br /> Injured? ❑Yes ❑ No Injured? ❑Yes ❑ No <br /> Describe Describe <br /> DRIVERS STATEMENT(Describe in detail-attach additional sheets if required) <br /> HSE-620 Incident, Near Miss&Loss Report Rev. 10-08 Page 4 of 6 <br /> L_ <br />