I was the operator of the vehicle involved in an accident on
_____________________, 20_______
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 _______________, 20_______
Signature of
(Claimant)______________________________________________Date ____________
Witness:
______________________________________
____________________________________
______________________________________
____________________________________