Witness Statement – SORM74

Immediately after receiving notice of any injury, the claims coordinator should determine the names, addresses, and telephone numbers of all witnesses to the incident. A statement should be taken from each witness and forwarded to SORM.

Filing Deadline:
The form must be received by SORM not later than the 5th calendar day after the first notice of injury is reported to the agency.

Completed by:
The person giving the statement, with assistance from the claims coordinator.


    1. Except for the witness’ signature, the witness statement form should be typewritten, if possible. If it must be handwritten, PLEASE PRINT.


    1. Be sure to fill in the claim number, if known.


    1. The witness may have actually seen the accident, or may have acquired knowledge about the accident from some other source. The witness’ information may relate to how the accident occurred or to something else that is relevant. Check the first or second box and fill in the blanks following those boxes, as is appropriate. Be specific and complete. Sometimes you will be given someone’s name as being a witness, who when asked, claims to know nothing about the accident. In such a case, the third box should be checked.


  1. If the space provided on the form is insufficient, attach additional
    sheets. Please be as specific and complete as possible.

Fax a copy or mail the original to:
State Office of Risk Management

Retain a copy for your file.