WITNESS STATEMENT QUESTIONNAIRE FOR PASSENGERS

Personal Details

1. Please confirm your full address and how long you have lived there?

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2. Please confirm your current occupation?

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The Accident
3. Please confirm exact location and time of accident

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4. Please describe:-

(a) Third Party vehicle registration number & Colour

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(b) Weather conditions – fine / bright / dull / cloudy / rainy / snowing
(c) Road conditions – dry / wet / greasy / icy
(d) Visibility – clear / dusk / dark / fog

Please provide a description of the incident. This description must include how the

accident happened.

5. Where did you set off from?

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6. Where were you heading?

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7. How much traffic was there on the roads at the time?

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8. Were you jolted in your seat as a result of the accident?

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9. If so, how. What was your speed and the third party vehicle speed at the time of the

accident?

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10. Did you see the accident happen? If not where were you looking?

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Please advise what happened after the accident.

11. Did you exit the vehicle with your driver?

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12. If you exited the vehicle, did you see damage to your car and the third party vehicle?

Where was this damage?

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13. Did you speak to the other driver? If yes, what was said?

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14. What did the third party driver look like?

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15. Did you call the police or ambulance? If not why not?

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16. Who do you blame for the accident and why?

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Please note you DO NOT have to answer question 17, but it would help the case if you

did.

17. Please prove a sketch of the incident. The sketch needs to show all vehicles involved

in the incident, the direction of travel and any road markings. Please also confirm

where you were in relation to the incident.

BEFORE THE ACCIDENT

AFTER THE ACCIDENT

My Injuries

18. Please confirm when you started to feel pain after the accident? Was it the same day?

Or the next day?

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19. Please advise if you visited your GP or Hospital as a result of the accident? If so, when

was this?

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20. If you did not visit your GP or hospital how did you manage pain? Did you take any
painkillers, if so which ones?
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21. How did the injuries from the accident impact your daily life? Did they affect any

activities you did or did they impact your hobbies? For example being unable to carry

our house chores, playing sports or sleeping properly etc.

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*Please note that the above answers have to be detailed and accurate. If any incorrect
information is provided it can severely affect the drivers claim and ultimately your
claim in the future.
STATEMENT OF TRUTH

I believe that the facts stated in this statement are true.

Name ..........................................................................................

Signed …………………………………………………………………

Dated .........................................................................................

Asons Solicitors
120 Bark Street
Bolton
BL1 2AX

Ref:
Solicitors for the Claimants

To: The Court and to the Defendant