I was the operator of the vehicle involved in an accident on _____________________ 19_______
at or near ______________________________________________________________________________________
The only other passengers/occupants in the vehicle were ___________________________________________________
To my knowledge no one in my vehicle sustained any bodily injury.  I did not sustain any bodily injury.  I have not had medical attention and have not suffered any financial loss as a result of this accident.

Dated at ________________  this ___________ day of _______________ 19_______

Signature of    (Claimant)______________________________________________Date ____________
 
 
 
 

                                                                                      Witness:
______________________________________                      ____________________________________
______________________________________                      ____________________________________