This statement is to be completed by an individual who witnessed an incident related to an insurance claim. Please be as detailed and objective as possible.
Claim File/Reference Number
Date of Incident
Time of Incident
Location of Incident (Address or Detailed Landmark)
Type of Incident
Vehicular Accident
Property Damage
Slip/Fall
Fire
Theft
Full Legal Name
Date of Birth
Street Address Line
Street Address Line 2
City
State/Province
Postal/Zip Code
Contact Phone Number (Mobile)
Contact Phone Number (Landline)
Email Address
Relationship to Claimant or Insured Party
None
Neighbour
Co-worker
Relative
Other:
Please describe in your own words exactly what you saw, heard, and/or smelled before, during, and immediately after the incident. Be specific about times, distances, speeds, and sequence of events.
Start from the moment you became aware that an incident might occur.
Date/Time of observation:
Statement:
Description | Party 1 (e.g., Insured, Driver, Claimant) | Party 2 (e.g., Other Driver, Property Owner) | ||
|---|---|---|---|---|
A | B | C | ||
1 | Name | |||
2 | Vehicle Make/Model/Color | |||
3 | License Plate/Registration | |||
4 | Direction of Travel/Activity |
Condition of the Area/Property: (e.g., Wet floor, icy road, heavy smoke, clear visibility, poor lighting)
Weather Conditions at the Time of Incident: (e.g., Sunny, rain, fog, snow)
What was the injured or damaged party/property doing just before the incident?
Did you see any immediate damage to property or vehicles?
If Yes, describe the damage and estimate where it occurred (e.g., Front fender of blue sedan, broken window on third floor).
Did you see any immediate injuries to any person?
If Yes, describe the nature and extent of the injuries and how the person reacted (e.g., Holding leg, bleeding from head, seemed conscious).
Did anyone admit fault or make a specific statement regarding the cause?
If Yes, what was the statement, and who said it?
Were there any other witnesses to the incident?
If Yes, provide their name(s) and contact details if known:
Name | Phone | |||
|---|---|---|---|---|
A | B | C | ||
1 | ||||
2 | ||||
3 | ||||
4 | ||||
5 |
Were any photographs or videos taken by you?
Please provide copies if applicable.
File Name | Upload File | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Was a Police/Fire/Emergency report filed?
If Yes, provide the name of the agency and the report/reference number (if known):
I declare that the information provided in this statement is true, accurate, and complete to the best of my knowledge and recollection.
I understand that this statement may be used by the insurance company in the investigation and resolution of this claim.
I am not under duress and have provided this statement voluntarily.
Witness Signature
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