Insured ___________________________
Date _____________________________
Telephoned _____ In Person ______
RECORDED STATEMENT SUMMARY
Name ___________________________________ Address
_________________________________
Insured
_____
Insd. Driver
______
Witness
_______
Claimant ______
Occupation _______________________________ Employer ________________________________
Home Phone ( ) _________________________ Business Phone ( ) ______________________
Appearance ______________________________ Intelligence
_______________________________
Nationality
_________________________________________________________ Age ___________
Appraisal of Witness ________________________________________________________________
Summary ___________________________________________________________________________________
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Adjuster __________________________ Date _________________________