State the year, make, and model of the vehicle involved, and the names of the
owners as they are registered.
State the time, date, and place of accident.
Please state the weather conditions and also the specific road conditions.
Did a law enforcement officer investigate the accident, if so, which municipality?
If you recall the name of the officer, please state the officer’s name.
Have you been contacted by an adjuster? If so, did you give anyone a written or
recorded statement? If so, please state when you did this and if you were supplied a copy of the statement.
Date of statement
Copy of statement
No copy of statement