Witness Statement
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1
2WITNESS STATEMENT
Injured Employee
MUST BE TYPED
OR PRINTED
SORM Claim Number WC
Date of Injury
Statement Taken By
Witness Name:
Witness email address:
Residence Address:
Primary Telephone:
Secondary Telephone:
Witness Employer:
On this date, ______________________, at about ____________PM / AM I was in or at (clearly state your own location)
when an accident involving the above
employee is reported to have occurred.
Check only one box
I saw the incident.
The accident occurred in the following manner:
Other pertinent information and source:
I did not see the incident. Information given to me by (name of person)
indicates it occurred as follows:
Other pertinent information and source:
I know nothing whatsoever about the occurrence.
____________________________
________________
Signature
Date
SORM74 Rev 07/09
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