Insurance Accident Sample Witness Statement

Obtaining clear and accurate accident information is crucial to your commercial insurance program. Claims reserves and loss ratios all have a direct impact on your commercial insurance policy pricing. It is important to gather all the appurtenant data in an auto accident, general liability accident, or workers compensation accident. Below is a sample form that can be used in gathering this information.

Day ______ date ______ time _____ _ am _ pm

Name ____________________ D.O.B. ____________________

Residence address:____________________________________

City _____________ state ___ Telephone:_______________

Business address _____________________ city ____________ state ___


Did you see the accident that occurred at? _______

Date of accident ______ time of accident ___ am ___pm

Where were you located ________________________________

What happened ________________________________________________________________

Was anybody injured? __________________

What statements did you hear parties make? __________________________________________________________________

Date:______________________ (signature)

Date:_______________________ (witness)

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