THIS SECTION MUST BE COMPLETED FOR ALL INCIDENTS
PROVIDE WRITTEN DESCRIPTION OF THE EVENTS LEADING UP TO AND DURING THE CASUALTY INCIDENT
(THE COMPANY MAY INSTRUCT AN ADJUSTER AND/OR ATTORNEY TO OBTAIN DETAILED STATEMENTS WHERE REQUIRED)
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IN COMPLETING AND SIGNING THIS DOCUMENT I AM FORMALLY REGISTERING A CLAIM FOR THE ABOVE INCIDENT AND AGREE TO ABIDE BY THE TERMS AND CONDITIONS OF THE POLICY IN ALL MATTERS RELATING TO THIS CLAIM
I HEREBY DECLARE THAT THE PARTICULARS AND ANSWERS GIVEN IN THIS STATEMENT ARE IN EVERY RESPECT TRUE AND CORRECT AND THAT I HAVE NOT WITHHELD ANY INFORMATION WHICH MAY INFLUENCE THE DECISION OF THE COMPANY IN REGARD TO THIS INCIDENT
