COMPLIMENTS OF 
 

On the following pages are STATEMENT GUIDES for various situations.  The most important point in using any statement guide is to listen 
to the answer given, before going to the next listed question.  How you follow up may be dependent on the answer to any given question.  Be sure to clarify any answer you do not understand before continuing. 

Be flexible and recognize that not every point on the guide will be applicable to every situation.  For example, if it is clear there is no injury involved, there may be no need to explore a person’s  wages, how many children he/she has, the children’s ages, etc. 

For the most part, following the guide will help jog your mind and insure that your statements are complete and that nothing important has been omitted. 

ORDER YOUR POCKET STATEMENT GUIDE 

Ordered by calling (614) 267-6992 or 
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MINIMUM ORDER         1  to   100 =   $10.50 each. 
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OPENING STATEMENT 
(All Statements) 

BEGIN WITH: 

This is _________________conducting a recorded interview 
 (your name) 
with______________________at______________________ 
 (person’s name)          (location) 

Today’s date is __________  The time is __________________ 

We are going to discuss details of an accident which occurred on________________ and in which ______________________ 
            (date of accident)          (interviewee’s name) 
was _______________________________________________ 
    (How involved- driver, witness,  passenger, pedestrian, etc.) 

Then continue with identification 
 
 
 
 
 
 
 
 
 
 
 
 
 

A.       OPENING STATEMENT 
IDENTIFICATION OF PERSON 
(All Statements) 

Are you aware this conversation is being recorded?  And is it being recorded with your permission? 
 

THEN IDENTIFY THE PERSON’S 

a. Name - address - phone 
b. Age and date of birth 
c. Marital Status - If married, spouse’s name 
d. Dependents - names, ages, relationship 
e.  Parents (if a MINOR) 
f.  Occupation 
g. Employer - address - phone - how long 
h. Other employment - part-time etc. 
i.   Any physical impairments 
j.   Can be reached at all times through whom? -                                                                    name, address, phone 
k. Hourly wage 
 
 
 
 
 
 
 
 

IDENTIFICATION (All Statements)    .1 
 

2. INJURIES 
(All Statements) 
 
 
 
 

a. Nature of injuries and extent (describe in detail - limit the injury) 
b. How caused? 
c. If unconscious - how long? 
d. Medical treatment at scene - by whom? 
e. Doctors - names and addresses 
f. Type of treatment - diagnosis - prognosis 
g. Hospital - where - how long 
h. Disability - type - beginning - ending 
i. Previous accidents - type - dates - doctors 
j. Medical bills - other expenses 
k. Paid - unpaid - by whom? 
l. Time off work - dates - anticipated return 
m. Wages - other income - any overtime? 
n. If fatality - expenses - burial plot - time between accident and death 

*SECURE: Medical and wage authorization 
 
 
 
 

2. INJURIES (All Statements) 
 
 

3. AUTO ACCIDENT GUIDE 

Statement of occupants of vehicle involved 

A.     Vehicle Involved 

1. Owner - address - phone - titled or 
     financial owner? 
2. Description of car - make - model - year - color 
3. Mechanical condition 
4. Driver - age - address - phone 
5. Driver’s license - restrictions 
6. Permission - limitations - used within scope of                     permission 
 

B.      Pre-accident Events 

1. Purpose of trip (agency - bailment) 
2. Departure point - destination - time 
3. Passengers - seated where 
4. Payment by passengers - how much, to whom, by whom, why paid 
5. Stops during trip - (driver - passenger out of car) 
6. Passenger objections to driving 
7. Any drinking - by whom - how much - when 
8. Any distractions of interference in vehicle 
 

AUTO ACCIDENT GUIDE  3 
C. Accident Location 

1. Date, time, place 
2. Description of road and scene (hills, curves, etc.) 
3. Weather conditions 
4. Condition of road (icy,gravel, etc.) 
5. Lighting - visibility 
6. Speed limit 
7. Traffic controls - working? 
 
 

D. Accident Details 

 1.  How did accident happen? 
 2. What caused accident to happen? 
 3. Speed before accident 
 4. Any other traffic? 
5.  Directions of vehicle involved? 
 6. Road position of vehicles - which lane? 
 7. When and where did vehicles first see each other             - when was danger first realized? 
 8. Distance - view - obstructions 
9.  Any signals given - any seen? 
10. Warnings by anyone - what kind? - when? 
11.  Attempts to avoid accident 
12. Speed of vehicles at impact 
13. Points of impact - on road - on vehicles 
 

B.   Accident Location & Details 
If pedestrian involved 
 - cover by any driver or witness: 
 
 
 
 
 
 

14. Location when first seen 
15. View obstruction - pedestrian - driver 
16. Distance away 
17. Direction pedestrian facing 
18. In crosswalk? - If not, how far from 
       intersection? 
19. Color of clothes - visibility 
20. Carrying anything - packages etc. 
21. Pedestrian - walking or running 
22. Was pedestrian distracted? 
23. Did pedestrian look before walking? 
24. Position of pedestrian when danger realized 
25. Evasive action by driver 
26. Evasive action by pedestrian 
27. What part of the car struck pedestrian 
28. Stopping distance of car 
29. Where was pedestrian after accident? 
30. Conversation after accident 
31. Evidence of drinking - intoxication 
 
 

If pedestrian involved     .C 
E. Post Accident Detials 

 1. Position of vehicles after accident 
 2. Stopping distances 
 3. Skid marks - both vehicles 
 4. Were skids measured - by whom - when - how? 
 5. Any debris from vehicles on roadway 
 6. Persons thrown from vehicle?  To where? 
 7. First person on the scene 
 8. Any conversation - with whom - what said 
 9. Were cars moved prior to police 
10. Police investigation - what dept. - any arrests? 
11. Any witnesses to accident - names - addresses 
12. Any intoxication tests made 
13. Know any other parties of accident 
14. Any injuries - who? 
15. Any ambulances - from where 
 
 
 
 
 
 
 
 
 
 
 
 

D.  POST ACCIDENT DETAILS 
F. Other Vehicles 

 1. Owner - name and address 
 2. Driver - name and address 
 3. Passengers - names - addresses - positions 
 4. Description of vehicle 
 5. Any injuries - complaints 
 
 
 
 

G. Damages (all vehicles) 

 1. Specific parts damaged 
 2. Extent of damage 
 3. Estimates of damage 
 4. Prior damage 
 5. General condition of car 
 6. Present location 
 7. Repairs authorized 
 8. Wreckers on scene - names - locations 
 
 

H. Injuries 

 If the interviewee was injured, obtain 
 details using the Injury Guide. 

I. General Information 

(This information may be obtained after conclusion of statement unless statement is taken specifically to obtain this information) 

 1. Insurance on vehicle 
 2. Other insurance 
 3. Worker’s Compensation 
 4. Medical Payments 
 5. Group Insurance 
 
 
 
 
 
 
 
 
 
 
 
 
 

F.     AUTO  INJURIES 
 
 

4. PASSENGER - SUPPLEMENT 

 (To be used in addition to Section 3) 

a. Prudence of driver 
b. Negligence of driver - why 
c. Ridden with before? 
d. Ride with again? 
e. Condition of driver 
f. Any objections to driving - if so, what said 
g. Who objected - when? 
h. Any stops - who got out - why 
i. Was anything paid for ride 
    - by whom 
    - for whom 
    - to whom 
    - what for 
     - how much 

j. Was payment requested? 
    - by whom 
    - for how much 
   - for what 
    - from what 
 
 
 
 
 

PASSENGER        .4 
 

5. WITNESS STATEMENT 
 
 
 
 

a. Identification 
b. Accident location  (Refer to Section 3C) 
c. Where witness located - specifically 
d. What attracted witness attention 
e. What was witness doing prior to accident? 
f. Witness view of accident 
g. What part of accident seen 
h. Coming from - going where 
i. Accident details  (Refer to Section 3D) 
j. Post-accident details - (Refer 3E) 
k. Describe vehicles involved 
l.    Drivers involved - names - addresses 
m. Passengers in vehicles 
n. Injuries 
o. Damage to autos 
p. Personally acquainted with parties involved? 
q. Did witness give statement to any other 
     person?  Recall any variation between it and             present statement? 
 
 
 
 

5. WITNESS 
 

6. GENERAL LIABILITY 
  (Building, Streets, Land, etc.) 

Used for statements of owner, tenant resident or witness 

A. Premises 

1.  Owner - name - address 
2.  Location - specific
3.  Type of premises 
4.  How occupied - owner, lessor, etc.? 
5.  Written lease or rental agreement 
6.  How used? 
7.  Condition of premises 
8.  Who had responsibility for area? 
9.  Who maintains? 
10. Who controls? 
11. Alteration - by whom - whose request 
12. Knowledge of defective condition 
13. When - how long 
14. Inspection of premises - by whom 
15. When last inspection - results 
16. Condition easily seen or hidden 
17. Previous complaints or accidents 
18. Description of defect - complete 
19. Cause - other party? 
    wear and tear? 
    weather - elements? 
    faulty construction? 
    negligence? 

20. Lighting - provided - required 
21. Weather conditions at time 
22. When area last cleaned, scrubbed, waxed, 
      or swept 
 
 

B. Post accident details 

1.  First knowledge of accident 
2.  Witness to accident - details - injuries 
3.  Why was injured on premises? 
4.  Was person on premises before - when? 
5.  How well are the premises known by this 
      person 
6.  Other witnesses 
7.  First aid given - by whom 
8.  Police investigation 
9.  Photos taken 
10. Repairs or removal of defect - by whom 
11. Claimant drinking 
12. Claimant impairment 
 

7. STATEMENT OF CLAIMANT 

A. Opening and Identification 
B. Pre-accident Details 

1.  Pinpoint location - description 
2.  Date and time - be specific 
3.  Purpose of trip - (status) 
4.  Route taken 
5.  Accompanied by anyone - who 
6.  Familiarity with premises 
7.  Previous visits 
8.  Weather Conditions 
9.  Lighting 
10. Distractions 
11. Drinking - how much - when - where 
12. Type of shoes (leather - rubber soles) 
13. Running - walking 
14. Previous knowledge of defect 

C. Accident Details 

1.  How did accident occur? 
2.  Cause - describe - be specific 
3.  Was defect or condition seen prior to accident? 
4.  Why not 
5.  Other parties involved 
    _ how 
    _ who - names - address 
    _ did what? 
    _ why 
6.  Any impairment (prior to accident) - glasses - cane - hearing aids 
 
 

GENERAL  --- CLAIMANT   .7 
D.  Post-accident Details 

1.  To whom was accident reported 
2.  By whom 
3.  What did you do after accident? 
4.  Anyone give assistance - who - how 
5.  Any first aid - by whom 
6.  Any witnesses - names - addresses 
7.  Where were witnesses? 
8.  What did witness say? 
9.  Any police investigation 

E.  Injuries 
    Refer to Section 2 

F.  General Information 
    This information may be taken after completion of statement. 

1.  Other Insurance 
2.  Worker’s Compensation 
3.  Group Insurance 
 
 
 
 
 
 
 

POST-ACCIDENT DETAILS 
 

8.  GENERAL WITNESS STATEMENT 

a.  Opening and Identification 
b.  Location of witness 
c.  Doing what 
d.  What attracted attention 
e.  Coming from - going to? 
f.  Date - time - place - be specific 
g.  How far from point of accident 
h.  Pre-accident details (Refer - 7B) 
i.  Accident details (Refer - 7C) 
j.  Post-accident details (Refer - 7D) 
k.  Describe injuries seen 
l.  Comments by claimant 
m.  First aid rendered - by whom 
n.  Know parties involved 
 
 
 
 
 
 
 
 
 
 
 
 
 

GENERAL — WITNESS   .8 
 
 

9.  PUBLIC LIABILITY - CONSTRUCTION 

A.  Buildings 

 1  Name and address of -owner -architect 
     -general  contractor -subcontractor 
 2. Who maintains premises? 
 3. Who controlled premises at time of accident? 
 4. Contracts or agreements -type -with whom 
      - copies available 
 5. Is work hazardous -in what way? 
 6.Experienceofworkmen-especially those in area           of accident 
 7. Safety measures taken - regulations 
 8. Safety Equipment - provided? used? 
 9. Permit to build - type - when 
10. Conformity of job to building and safety codes 
11. Any inspections - who - when 

B.  Road construction 

 1. Who had control of area at time of accident? 
 2. Description of construction area - detailed 
 3. How long under construction 
 4. Any flares - signs - barriers 
    IF NOT - WHY NOT 
    Were signs and barriers visible 
    Were they checked - by whom - how often? 
 5. Any other factors - wind - rain, etc. 

9  GENERAL CONSTRUCTION 
 
 

10.  FLOOR ACCIDENTS 
 

a. Composition of floor 
b. Age of floor 
c. General condition of floor 
d. Condition of floor in area of fall 
e. If wet - why - how long 
f. Any warning signs - why not 
g. Any other obstructions or debris? 
h. If slippery because of wax - 
   when waxed last 
   by whom 
   what kind of wax 
   who manufactures? 
   who distributes 
   who retails 
   wax paid for or given as sample 
   receipt 
i. Carpets - rugs - mats involved 
   Non-skid type - glued or nailed 
   In usual place 
   Condition of mats, etc. - loose or torn 
j. Notice 
   How did condition exist? 
   How long did you know about it 
   Any warnings - verbal - signs 
   How did you know of accident? 
 

10.  FLOOR ACCIDENTS 
 

11.  SIDEWALK ACCIDENTS 
 

a. Type of sidewalk - cement, stone, etc. 
b. Condition - cracked - broken 
c. Location - be specific 
d. Level or sloped 
e. Public or private sidewalk 
f. If public - any notice to city 
g. Cause of defect 
h. How long had defect been there 
i. Knowledge of defect by claimant 
j. Claimant doing what 
k. Looking where 
l. Defect obvious? 
m. Attempts to repair - by whom - when 
n. Sidewalk whose responsibility 
o. Original builder 
p. If snow or ice 
   cause of ice? 
   snow last fell? 
   walk covered - how? 
   any attempts to remove? 
   how? 
   by whom? 
   when? 
 
 
 

11.  SIDEWALK 
 

12.  STAIRWAYS 
 

a. Location of stairs - be specific 
b. Area of stairs where accident occurred 
c. Description of stairs 
d. Construction of stairs 
e. Measurements of stairs 
f. Number of steps 
g. Height of risers uniform 
h. How high 
i. Steps covered - how - (mat - carpet) 
j. Condition of covering 
k. Nosing on steps - condition 
l. Conformity to building code 
m. Handrail - condition - location 
n. Was handrail used? 
o. Lights - switch location 
p. Any obstructions 
     on stairs 
q. What caused fall 
r. Familiarity with steps - defect 
s. Who is responsible for stairs? 
t. Who maintains stairs 
u. Other falls or accidents on these stairs 
    - who - when 
 
 
 

12. STAIRS 
 
 

13. PRODUCTS LIABILITY 

Statement of owner or seller regarding the product involved. 

a. Name of product 
b. Name and address of manufacturer 
c. Type of product 
d. Intended application of product 
e. Description of - 
     1.) Label of product 
     2.) Warnings labeled on product 
     3.) Directions given with product 
     4.) Warnings given with directions 
     5.) Verbal warnings given 
     6.) Any demonstrations given - by whom 
f. Model and serial numbers 
g. Any coding numbers 
h. Who recommended product - why? 
i. Product suggested by retailer? 
j. Date of purchase - any receipts - delivery date 
k. Purchased from whom? -Price? 
l. Describe defect of condition 
m. First knowledge of defect 
n. First complaint - when - who 
o. Any recalls by manufacturer 
p. Date of recall 
q. Date recall notices sent out 
r. Where is product now? 
s. Who has inspected product - findings? 
t. Had product been altered - by whom - why? 
u. Any safety devices on product 
v. Had these been removed - by whom - why? 
w. What was product being used for? 
x. Is product designed for this purpose? 
y. Was product sold for this purpose? 

13. PRODUCTS 

14. PRODUCTS - CLAIMANT STATEMENT 

A. Opening and Identification 

B. Pre-accident Details 
 1. Name and address of purchaser 
 2. Purchased for whom - why 
 3. Price paid - to whom 
 4. Date of purchase 
 5. Purchased - new - used 
 6. Name of person from whom purchased 
 7. Salesperson 
 8. Date delivered - by whom 
 9. Set up by whom 
10. Condition at time of delivery 
11. Product inspected at time of delivery - by whom 
12. Instructions with product 
13. Warnings with product 
14. Warnings on product 
15. Demonstration of product - by whom 
16. Verbal warnings - by whom 
17. Others using product - who 
18. Any alterations to product - by whom 
19. Safety equipment - 
     Required? 
     Supplied? 
     Used? 
20. Were instructions followed - warnings? 
21. Description of product 
     a. name 
     b. Type 
     c. Model number 
     d. Serial number 
     e. Coding number 
22. Why was this product purchased? 
     Recommended by retailer 
     Recommended by manufacturer 
23. Product was being used for what? 
24. Describe defect or faulty condition thoroughly 
25. Who first noticed defect? When? How? 
26.Was product used after defect noticed?  Why?  By whom?  For what? 
27. Who was notified of this defect? 
     What was done? 

C. Accident Details 

1. Date, time, place (exact) 
2. Describe what happened (detailed) 
3. Any witnesses - names 
4. Any co-workers 
5. If food involved 
     Who ate same thing? 
     Other food eaten? 
     Anyone else sick?  Who? 
6. Incident reported?  To whom?  When?  How? 
7. Police investigation 

D. Injuries 
     Refer to Section 2 
 

A.  PRODUCTS - CLAIMANT 
 
 

15. WORKER’S COMPENSATION 

a. Opening and identification 
b. Description of incident 
c. Accident? (sudden? unplanned?) 
d. Arising out of employment? 
e. Arising in course of employment? 
f. Notice of injury given? 
     to whom? 
     when? 
     how? 
g. Witnesses - names - addresses 
h. Deception of injury - (detailed) 
     Be specific - limit injuries 
i. Treatment 
     First aid - by whom 
     Doctors - names - addresses 
     Hospital - address 
j. Disability - type - duration (dates) 
k. Off work - dates 
l. Wages 
m. Date employee last worked 
n. If returned to work - date and salary 
o. Employee?  Independent contractor?  Excluded employment? 
p. Personal deviation - violation of safety regulations? 
     horseplay? 
q. Third party responsible - who?  why? 
r. Detailed past medical history. 
 
 
 

15. WORKER’S COMPENSATION 
 

16. FARMOWNER LIABILITY - LIVESTOCK 

Used when farmer’s livestock have gotten out causing damage 

a. Opening and identification 
b. How large is farm 
c. What are major products - crops - livestock? 
d, How many head of livestock? 
     Cattle?     Hogs?     Sheep? 
e. Where are livestock kept? 
f. Condition of fences, pens, etc. 
g. Age of fences 
h. Type of fences 
i. Do the pens, fences etc. keep the animals in? 
j. How did animals get out? 
K. Any fences or pens broken? 
      How many got out? 
m. When did they get out? 
n. How long out? 
o. Were you aware they were out?  Why Not? 
p. How were you notified they were out? 
q. When? 
r. Ever been out before?  How many times? 
s. Why did they get out?  (Lighting etc.) 
t. Did animals have enough food and water? 
u. Did animals get out through line fence? 
     Whose end? 
     Who’s responsible for fence? 
v. What damage caused by animals? 
w. Who owns damaged property? 
x. Are you sole owner of animals? 
y. How often do you check fences? 
z. When was last check prior to animals getting out? 
aa. Description of animals 
     1. Type 
     2. Size 
     3. Market Value 

16. FARMOWNERS LIABILITY - LIVESTOCK 

17. FIRE STATEMENT GUIDE 

 1. Opening and Identification 
 2. Do we have your permissions to enter upon your property? at (location) and investigate the fire and remove any evidence that may point to the cause of the fire? 
 3.  If necessary, do we have your permission to return t o your property at a later date to collect evidence from  the fire? 
 4.Do you have other sources of income than from your  regular employment? 
 5. Were you the owner of the property located at ___________  at the time of the fire? 
 6.Are you the sole owner?  If a partnership, who is the  other owner. 
 7. Is your spouse on the deed to the property? 
 8. Have any pets?  Were they injured in the fire? 
 9. How long have you owned the property? 
10. Did you and your spouse/children live in the house? 
11. Where were you when the fire occurred? 
12. How did you find out about the fire? 
13. Who was the last person in the house? 
14. Did you personally lock up the house when you left? 
15. Have you had the locks changed since you have owned the house? 
16. Who had keys to the locks? 
17. Have you had any burglaries or prowlers? 
18.Were there any signs of forcible entry when the fire department arrived? 
19. Any electrical problems recently? 
20. Any heating or furnace problems recently? 
21. Any TV. problems recently? 

FIRE STATEMENT GUIDE  .17 

22. What utilities do you have?  Gas - electric -  phone were  they on? 
23. Do you or your spouse smoke?  Were you smoking before leaving?  the house?  Exactly where? 
24. Did you have any visitors prior to leaving the house? 
25, Do you know for sure how the fire started? 
26. Do you have any idea how the fire started? 
27. Did you have anything to do with having the fire set? 
    Did you yourself set the fire? 
28. Were there any flammable liquids stored in the building? 
29. Ever had a fire before in this or any other property? 
30. Ever had an insurance claim before?  What company, when   and where? 
31. Has the property been for sale recently or were you going?  to sell it? 
32. Has the house been appraised recently?  If yes, what value    and why the appraisal? 
33. What condition was the structure in before the loss?   Did the roof leak? 
34. Done any remodeling recently?  Exactly what? 
35. Any evidence of bugs or termite infestation? 
36. Purchase price of home?  From?  When? 
37. Where is the house financed?  Amount of monthly payments?   Current or in arrears? 
38. How long have you lived in the house? 
39. Where did you live before?  Did you own other property? 
40. If rented property, are the rent payments current or in arrears? 
41. Do you have any other loans or debts? 
    List where, amount monthly payment and if current or in arrears. 
42. Do you have any other insurance besides this policy?  List. 
43. Was anything removed from the building prior to the fire?       After the fire? 
44. Did you find anything missing after the fire that would indicate a burglary? 
45. Are you planning to rebuild the property? 
46. Can you think of anything else that would help with the  investigation? 
47. Were there any liens or judgments against you or the property? 
48. Are there any health, sanitation, zoning or building     violations against the property? 
49.Any county, township,or city violations against the property? 
50. If a business establishment, what was the approximate amount of daily or weekly 
business (net) 
51. What steps have you taken to preserve and protect this property?