STATE OF [State Name]
COUNTY OF [County Name]

Introduction:

I, [YOUR NAME], residing at [YOUR ADDRESS], being duly sworn, do hereby depose and state the following:

Statement of Facts:

1. My name is [YOUR NAME], and I am over the age of eighteen years and have no interest, either direct or indirect, in the outcome of the insurance claim related to the accident described herein.

2. On [Date of Accident], at approximately [Time of Accident], I was located at [Your Location at the Time of the Accident] when I witnessed an accident involving a black sedan and a white pickup truck colliding at the intersection of Main Street and Elm Avenue.

3. The accident occurred at the intersection of Main Street and Elm Avenue. I observed a black sedan traveling eastbound on Main Street fail to stop at a red light and collide with a white pickup truck traveling northbound on Elm Avenue.

4. The weather was clear, and visibility was good at the time of the accident. After the collision, both drivers exited their vehicles and appeared to be uninjured, but visibly shaken. Emergency services were promptly called to the scene, and bystanders assisted in directing traffic and providing aid until help arrived.

5. I immediately called emergency services to the scene and ensured that both drivers were attended to while assisting in securing the area to prevent further accidents.

6. Additionally, I provided my account of the accident to law enforcement officers upon their arrival, detailing the sequence of events leading up to the collision and any observations I made regarding the actions of the drivers involved.

Sworn Oath:

I make this affidavit voluntarily to provide an account of my observations regarding the aforementioned accident for the purposes of an insurance claim by [Name of the Individual or Entity Filing the Claim].

I understand that this affidavit is made under oath and declare that the information provided herein is true, complete, and accurate to the best of my knowledge, information, and belief. I am aware that providing false statements under oath may subject me to penalties under the law.

Subscribed and sworn to (or affirmed) before me this [DAY] of [MONTH], [YEAR], by [YOUR NAME] who is personally known to me or who has produced [Type of Identification] as identification.

Signature:

[YOUR NAME]

[DATE]

[Notary's Name]

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