Accident Statement Form

January 18, 2011 | By | Reply More

An accident statement form is a document that needs to be filled by an individual who is injured after meeting with an accident. The purpose of filling this form is to claim for any losses arising due to the accident and helps to get the loss compensated.

Sample Accident Statement Form:

Details of the applicant:

Name: _____________

Address: Street address __________ City name _________ State ___________

Postal code ______________

Home contact number: _____________    Mobile number: ___________

Email id: _____________

Details of the vehicles you were driving at the time of the accident:

Vehicle registration number: ______________

Date of registration: ___________

Current value: _____________

Make: ______________

Model: ________________

Name of the registered owner: ___________________

Accident details:

Date of the accident: ___________

Time: _____________

Location: __________________

Did you get injured?

a)   Yes

b)   No

Do you feel that it was your fault?

a)   Yes

b)   No

How was the weather condition?

________________________

Did the car suffer any damage?

a)   Yes

b)   No

What was the speed of the car?

______________________

___________________________

Signature of the applicant

Dated: _______________

Category: Statement Forms

Leave a Reply