Car Insurance | Witness Statement

*Denotes compulsory field

About the claim

Our customer's name if you know it

Our claim reference number (our adviser should have given you this) *

About the incident

When did the incident happen? *

Did you see the incident happen? *

Were you aware of any passengers in either vehicle? *

Did anyone appear to be injured? *

Is anyone involved in this incident known to you? *

If anyone you know who was involved

If you spoke to anyone involved at the scene, please let us know who and what was said

Where were you when the incident happened? *

Roughly how fast were the vehicles going? *

Please tell us how the incident happened *

Who do you think was to blame for the incident and why? *

About the vehicle that caused the accident

Vehicle registration if you know it

Vehicle make and model if you know it (e.g. Ford Focus)

Vehicle colour if you know it

Were the police involved?

Did you make a statement to the police? *

Name of police force

Police station address

Town or city

Please upload supporting evidence

If you'd like to upload photos taken at the scene, a diagram of the road layout or any other evidence, you can attach them here

Choose file

About you

Your title

First name *

Surname *

Your address *First line of address

Your addressSecond line of address

Your postcode *

Declaration

Would you be willing to go to court to give this statement? *

Please enter your full name to confirm the information you have given is a true reflection of the incident as you witnessed it *

WITNESS STATEMENT