EMPLOYEE OR WITNESS / THIRD PARTY STATEMENT FORM

• COMPANY LOCATION

  Select

• STATEMENT TAKEN ON THIS DATE AND TIME

  Date

• DATE AND TIME OF THE INCIDENT / ACCIDENT / INJURY OR OTHER OCCURENCE

  Date

• I AM PROVIDING THIS VOLUNTARY STATEMENT FOR PELICAN WASTE AND DEBRIS ON MY OWN FREE WILL WITHOUT ANY COHERSION OR PROMISES. TO THE BEST OF MY KNOWLEDGE THIS IS A TRUE AND CORRECT ACCOUNT OF MY RECCOLECTION TO THE INCIDENT / ACCIDENT / INJURY OR OTHER OCCURENCE.

  Yes

  No

• CHOOSE ONE

  VEHICLE ACCIDENT

  INJURY

  OTHER INCIDENT

• IF YOU HAVE CHOSEN "OTHER" PLEASE LIST THE TYPE OF INCIDENT

• WERE YOU INJURED AS A RESULT OF THE OCCURENCE ?

  Yes

  No

PLEASE DESCRIBE YOUR ACCOUNT TO THE INCIDENT / ACCIDENT / INJURY OR OTHER OCCURENCE IN AS MUCH DETAIL AS YOU CAN REMEMBER.

• undefined

• PHONE NUMBER OF INDIVIDUAL MAKING THE STATMENT

• SIGNATURE OF INDIVIDUAL MAKING THE STATEMENT

  Sign