Recorded / Witness Statement

Please fill out the following information and someone will contact you shortly.

Request Form

Please enter today's date:
What is the claim number, if applicable?
What is the Date of Loss?

Please enter the following information about the person to be questioned.

Name:
Street 1:
Street 2:
City:
State:
Zip:
Home Phone:
Cell Phone:
What is the witnesses's SSN?
What is the witnesses's date of birth?

What exactly would you like Stop Loss, Inc. to do for you? Please be specific.

Should this recorded statement be conducted via telephone or in-person?

Telephone
In person

What is of particular concern to you in regard to the injury claim?

Is claimant currently

Working,
on light duty or
off work due to his injuries?

If there is anybody at the insured with whom we can confer about the claimant in a confidential manner, please list their contact information below:

What is your name, company name, address and phone number?

Your Name:
Company Name:
Phone Number:
Email:
Street 1:
Street 2:
City:
State:
Zip: