Witness Motor Vehicle Collision Report Statement

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PIN NO:
CASE NUMBER:
TODAYS DATE/TIME:
WITNESS MOTOR VEHICLE COLLISION REPORT STATEMENT
NAME:
LOCATION OF COLLISION:
DATE AND TIME OF COLLISION:
I WILL STATE:
I consent to any and all information contained within this statement and form, including the accident report to which this
statement relates, to persons or agencies, directly or indirectly affected by the motor vehicle collision, including but not
limited to insurance companies or their representatives, property owners, investigators and legal representatives acting on
their behalf.
SIGNATURE: _______________________________________________________________

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