Complete the form

1. Scene of the accident

Civic number

*This field is mandatory.Street

Apartment

*This field is mandatory.City

Postal code (A9A 9A9)

Telephone number (555 666-7777)

Extension

For instance, the number of the local and/or the device.

2. Date of the accident observed

Indicate, to the best of your knowledge, the date and time where the accident occurred.

Date (day/month*This field is mandatory./year*This field is mandatory.)

Hour

3. Description of the accident

Yes

No

I do not know

*This field is mandatory.Describe in a few words the facts you wish to report.

4. Your details

Last name

First name

Name of the organization you represent (if any)

Telephone number (555 666-7777)

Extension

Other telephone number (555 666-7777)

Extension

E-mail address

Please confirm e-mail address

5. Do you authorize the Régie du bâtiment du Québec (RBQ) to communicate with you?

If you check “No”, please make sure that you have provided a complete set of information, in order that your reporting may be processed.

Yes

No

1. Scene of the accident