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OTIE- <br /> O.eba 1d.i inrop.•�a En•.v.+.+ <br /> GENERAL LIABILITY REPORT <br /> Page 1 of 1 <br /> PROPERTY DAMAGE AND LOSS <br /> Facility Name and Address: <br /> Project Name/Number: <br /> Description of Property Damage or Loss: <br /> Estimated $Value of Damage or Loss: <br /> Location of damaged/lost/stolen property(before loss): <br /> Were Pictures Taken of Damage? Were Police Notified? Yes or NO <br /> YES or NO Department: <br /> Report No.: <br /> Date and Time of Damage/Loss/Theft: <br /> Were Hazardous Materials Released? If YES, describe materials: <br /> YES ❑ or NO ❑ <br /> Owner of Damaged/Stolen Property: <br /> Address: <br /> Telephone No: <br /> Personal Injuries? YES [ or NO (If YES, complete the section below) <br /> Complete an OTIE- TN&A CORPORATE Accident Investigation Report for injured <br /> employees <br /> Injured parties: <br /> 1. Name: Telephone No: <br /> Employer: Address: <br /> 2. Name: Telephone No: <br /> Employer: Address: <br /> Witnesses: <br /> 1. Name: Telephone No: <br /> Employer: Address: <br /> 2. Name: Telephone No: <br /> Employer: Address: <br /> Investigated by: Print Name Signature Date <br /> Employee <br /> Supervisor <br /> Reviewed by: Print Name Si nature ==Date <br /> Corp. SHM <br />