Witness Statement (Motorcycle Passenger)

(Please answer all questions fully)

What is your name? ____________________________________________________________ Date of Birth: _______________________________

Your home address: ______________________________________________________________Primary Tel: _______________________________

Your business address : _____________________________________________________________________________________________________

Email: ____________________________________________________________________Secondary Tel: __________________________________

Did you observe the motor vehicle prior to their collision? Yes No

If your answer is yes, please state.

A) What was the approximate speed of the motorcycle? _____________________ mph.

B) Where was the motor vehicle when you first observed it? _______________________________________________________________________

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C) Describe the motor vehicle, as to make, model, color. __________________________________________________________________________

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D) What was the speed of the motor vehicle when you first observed it? _______________________mph.

If the accident occurred at an intersection please state:

a) Did the motorcycle or motor vehicle enter the intersection first? _________________________________________________________________

b) Speed of the motorcycle as it entered the intersection? __________________________mph.

c) Speed of the motor vehicle as it entered the intersection? _________________________mph.

d) Any traffic control? Yes No If your answer is yes, describe the type of traffic control and its location:

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On what street and in what direction was the motorcycle traveling? ________________________________________________________________

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On what street and in what direction was the motor vehicle traveling? ______________________________________________________________

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Was any signal give by either driver prior to collision? Yes No

If so, please describe who gave the signal and what type: _________________________________________________________________________

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What parts of the motorcycle and motor vehicle made contact upon initial contact? ___________________________________________________

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What was the speed of the two vehicles as they collided? Motorcycle ____________________mph, motor vehicle _______________________mph.

What were the road conditions at the time of the accident? Dry Wet Icy Snowy.

Claim #:

Were you injured in the accident? If so, what injuries did you receive? ______________________________________________________________

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If being treated for the injuries, state name and address of doctor: __________________________________________________________________

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Please list names and addresses of any other possible witnesses: ___________________________________________________________________

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Did either driver make any state as to the cause of the accident? Yes No. If yes please explain: ___________________

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In your opinion who was to blame for the accident? _____________________________________________________________________________

Are you acquainted with anyone involved in the accident? ________________________________________________________________________

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Did the operator of the motorcycle or the motor vehicle violate any traffic controls (Traffic signal, stop sign, yield sign, blinking light)? If so please

describe: ________________________________________________________________________________________________________________

State in your own words just how the accident happened: ________________________________________________________________________

______________________________________ __________________________________________________________________________________

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Click HERE to access an accident diagram.

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

I certify that I have given truthful information in this report. (Check on electronic version only)

WITNESS STATEMENT (Continued)

Signature: ___________________________________ Date: _____________________________