anuary 2015
NORTH CAROLINA WITNESS STATEMENT FORM
Instructions: Before providing the required information below, please note that you will have to certify the truthfulness of this information. You will also be required
to acknowledge that you understand that in addition to being disciplined for providing false and/or misleading information, up to and including dismissal, you may
also be subjected to additional criminal and/or civil
liability.
To help
ou
rite
this
sta
ement, please
include,
if possible,
the
following
information:
Type of Investigation:
Safety Incident Accident Review Near Hit Property Damage
Witness Information
Name: Title:
Work Address: Work Phone #:
Incident Information
Date of Incident: Time of Incident:
Location of Incident:
Do you have any pictures of the incident?
If yes, please attach them to this submission.
Yes No
List the names of anyone present who observed or may have knowledge of the incident.
State what you know about the incident. Indicate who, what, where, and when. Be as specific as possible. If you need more space than what is provided here, create
a Word document and attach it to this submission.
I hereby certify that the information I have provided is true and accurate. I acknowledge that any inaccurate or false statements may result in a delay in process of
this claim. I further understand that this information may be used to determine whether the claim will be paid or denied.
Witness Name: Witness Title:
Signature: Date of Statement: / /
