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) | |
|---|---|---|---|
Name | |||
Vehicle Make/Model/Color | |||
License Plate/Registration | |||
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?
Did you see any immediate injuries to any person?
Did anyone admit fault or make a specific statement regarding the cause?
Were there any other witnesses to the incident?
Were any photographs or videos taken by you?
Was a Police/Fire/Emergency report filed?
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