Witness Statement Form printable pdf download

Witness Statement Form

Employer’s Indemnity Witness Statement

Claim no.

Policy no.

This form should be completed and returned to CGU within 7 days of receipt by the insured.

Please print in block letters and answer all questions. Tick

where applicable (provide full and complete answers).

If a particular question does not apply, please write “Nil” in the space provided. If the space provided below is insuf cient

to advise all the details, please attach a separate sheet.

Statement

In support of claim by

I, Mr, Mrs, Miss, Ms (Name)

Address

Postcode

Employed by

Occupation

Are you an actual eye witness?

Yes

Are you a work colleague having knowledge of the occurrence?

Yes

Being a work colleague having knowledge of the occurrence giving rise to the disability

hereby certify that

the particulars hereunder are an accurate description of the occurrence.

Details of occurrence

Date of occurrence

Time

am/pm

If you were an eye witness, describe fully the occurrence giving rise to the disability.

If you were a work colleague having knowledge of the occurrence giving rise to the disability, state fully the source and

circumstances from which knowledge of the occurrence was obtained.

continued overleaf...

Witness Statement Form