Commercial Auto Insurance Non-Injury Statement

While the Non-Injury Statement form below is not a legal document, but it can be a valuable tool in adjusting an auto accident in you favor. Getting positive statements from all parties involved can help negate a change of mind later on after they talk to an attorney and decide to seek damages.

To whom it may concern:

I, _________________________________________ DOB __________

Address ___________________________________________________

City _____________________

State ______ Telephone: ____________

was a passenger in ___________________________________________ owned by

__________________________________________________ and operated by


on the date of ___________ at ___ o’clock __ am __ pm,

when we were involved in a collision with a __________________________

owned by _________________________________ and

operated by _______________________________

and which occurred at, or near, ________________________________ I

further state that I was not injured in any way, nor did I suffer any personal loss of any kind, as a result of this accident. I have read,
fully understand, and state that I have signed this Non•Injury Statement, and it is true.

Dated: _______________ (signature) __________________

Dated: ________________ (witness) __________________

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