Were there any witnesses to the accident? If so, please list their names and
addresses (if known). Please state if you know the witness, aside from this accident.
Were there other injuries in the same accident? If so, how many people were
hurt and who were they?
Please state the name of the contact person with your employer to verify time
loss from work resulting from this accident, and in order to obtain a statement as to your
hourly, weekly, or average wage.
Title or position