SUPPLEMENTAL WITNESS STATEMENT-Belmont Assembly Of God Incident & Accident Report

This form is an optional addition to the main incident and accident report form.

It would typically be used to help explain how a personal injury or accident occurred when there are more complicated details to describe that cannot be fully addressed on the main form. it may also be used in the event of property damage or theft where similarly there are extensive details to document by a witness to the incident.

We recommend that this supplemental form be filled out by the same witnesses identified on the main form and shall become a part of the primary form when submitted.

Your name *

Email address *

WITNESS IDENTIFICATION

Name of Witness *

Age *

min: 0 / max: 100

Address *

Home Phone

Work Phone

Cell Phone

Were there other witnesses to this event besides yourself? *

Please state Yes or No. If yes, please provide names of other witness, if known.

This is related to an Incident and Accident Report identified as follows *

Date of Original Report: *

Was this Personal Injury/Accident or Property Damage/Theft? *

Please state which it is.

WITNESS SUPPLEMENTAL STATEMENT

Please use this space to provide any information or details that you wish to describe concerning the incident or accident that you were a witness to. *

This would be information you believe to be useful to help us further understand what took place that you could not fully elaborate on the main report.

Privacy Notice

Submission of this form along with contact information constitutes automatic approval for Belmont Assembly of God to communicate with the form submitter, witnesses, incident/accident victims, and any other identified parties for additional information if needed. In the event of incidents or accidents involving an insurance claim or police reports, we reserve the right to provide contact information to authorized agencies only to the extent necessary to resolve pertinent matters.

Name of Witness *

Date Signed *