This form must be filled in by the supplier of the piped gas or in the case of LPG in a refillable container, by the filler, importer or supplier (not the retailer).

If over 6 people were injured as a result of the incident, please do not complete the form and ring us directly on +44 1624 685881

This form can be used to notify Flammable Gas Incidents or Dangerous Gas Fittings covered by the:

• Health and Safety at Work etc Act 1974 (as applied to the Island)
• Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1985 (as applied to the Island).

Unless specified, all fields must be completed.