PERSONAL INJURY WITNESS REPORT FORM : MOTOR VEHICLE ACCIDENTName of Client: File No.: Current Date: Date of Accident: 1. Name 2. Date of Birth3. Marital Status4. Home Address/Phone Number5. Business Address/Phone Number6. Occupation7. Name/address/phone of person who will always know how to contact you.8. What, if any, is your relationship to the parties to this accident?9. Recollection of accident: a. Do you recall the accident? b. When did it happen--time and date? c. Where did it occur? d. Please describe the motor vehicles involved in the accident (make/model/year/operating condition/appearance).>>>> 2e. Where were you when the accident occurred?f. Were you wearing a seat belt? Was the driver/passenger wearing a seat belt?g. Describe everything you saw and heard. 1) Lighting 2) Weather conditions 3) Condition of road or pavementh. Describe everything you did as a result of the accident.i. What were you doing immediately before the accident?j. Where were you going?k. Where were you coming from?l. Did anything obstruct your view of the accident?m. Was the accident a result of a particular defect (improper lighting, defective sign, nonfunctioning traffic signals, bumps or holes in the pavement, etc.)?>>>> 310. Do you have a problem with eyesight? If so, please explain. Do you wear eyeglasses?11. Did you do anything after the accident? (Did you give statements? Did you talk to any parties or discuss the accident with anybody?) If so, please give details.12. If you heard any conversations, who said what to whom, and who else was present to hear comments?13. Did anyone admit fault or responsibility for the accident? Yes No If so, describe what was said, who was present when admission was given, and location of conversation.14. Medical Injuries a. Did anyone appear to be injured in any way? If so, describe your impressions. b. Was any medical assistance rendered at the scene of the accident? c. If so, by whom? d. Where was the injured person taken?>>>> 415. Was notice given to your employer/immediate supervisor? (When? By whom?) Method of notice (verbal or written)? 16. Since the accident, have you been contacted by anyone to discuss your knowledge of it? If so, please give details. 17. Have you given any statements or signed any reports regarding the accident? If so, please give details. 18. Have you ever testified in any court proceeding before? If so, please give details. ACKNOWLEDGMENT I have read the above statement, and it is true and accurate to the best of my knowledge,recollection, and belief. WitnessSubscribed and sworn to before me on this day of , __ . Notary Public