Witness Statement

Step 1 of 2

Company Employing Injured Worker*
Name of Witness*
First Last
Name of Injured Worker*
First Last
Witness Email Address*
Witness Phone Number*
Company Employing Witness*
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Date of This Report*
MM slash DD slash YYYY

Date of Incident*
MM slash DD slash YYYY
Time of Incident

: Hours

Minutes

AM/PM
Date Employee Reported Incident
MM slash DD slash YYYY
Client Where Incident Occurred (For staffing companies only)
Address Where Incident Occurred*
Street Address Address Line 2 City State ZIP Code
Are you related to the injured worker?*
- Yes
- No
Please list your relation*
How long have you known the injured worker?*
Did you actually see the incident?*
- Yes
- No
Explain, in detail, what you saw or know regarding this incident*
List the names of any other persons who may have information regarding this incident
Is there any other information that you know that would assist in providing a fair evaluation of this incident?
By submitting this form, you agree that...
By submitting this form, you agree that you are signing this form electronically and that all information you provided to InSource Employer Solutions / Business Insurers of Georgia is complete and accurate to the best of your knowledge. You agree your electronic signature (hereafter referred to as "E-Signature") is the legal equivalent of your manual signature. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You acknowledge your understanding that any person who knowingly submits false or fraudulent information is guilty of a crime and may be subject to fines and/or confinement in state prison.
By submitting this form, you agree that you are signing this form electronically and that all information you provided to InSource Employer Solutions / Business Insurers of Georgia is complete and accurate to the best of your knowledge. You agree your electronic signature (hereafter referred to as "E-Signature") is the legal equivalent of your manual signature. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You acknowledge your understanding that any person who knowingly submits false or fraudulent information is guilty of a crime and may be subject to fines and/or confinement in state prison.
Do You Agree to the Above?*
- Yes, I agree
Please Type Your Name*
First Last
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For Internal Use Only (Routing)
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MTWR-D
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F-D
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WKND-D
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HOL-D

Step 1 of 2

By submitting this form, you agree that...

For Internal Use Only (Routing)