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 __________________________