Claim No. _______________ Insured ___________________________ Date of Loss _______________________

Statement of: ________________________ Date of Birth ________ Age _______ Phone # ______- ____________
                                           (      ) Insured                                  (       ) Claimant                                         (      ) Witness

Address ______________________________ City ___________________ State ________ Zip Code __________

Employed ____________________________ Occ. ____________________ Wages __________ other _________

Weather Conditions ________________________________ Floor/Ground _________________________________

Obstacles/Obstructions _________________________________________________________________________

Witnesses/other _______________________________________________________________________________

Facts:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Who is at fault and why:
 
 
 

Injuries:
 
 
 

Doctor ___________________________________ Hospital ____________________________________________

Date Statement Taken _______________ Claims Rep. ________________________________________________

          RECORD STATEMENT SUMMARY