Claimant Statement Form

Gather the key facts of an incident directly from the affected party to support the review and resolution of an insurance claim.

Use this template

Name

First Name

Last Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

Email

Date of Birth

Occupation

Date and Time of Incident

Location of Incident

Description of Incident

Property Involved (if applicable)

Persons Involved

Type of Claim

Property Damage Bodily Injury Theft Other

Description of Damage or Injury

Emergency Services Notified

Actions Taken

Witnesses (if any)

Photographs or Documentation

Claimant Statement

Acknowledgement

I confirm this statement is true and accurate

Claimant's Signature

Sign here

Date

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