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Contractors Pollution Liability · Loss Reporting

Incident Witness Statement

For anyone who saw or heard a spill, release or other pollution incident. Use it with the Spill or Pollution Incident Claim Form. Fields marked are required.

Active spill, injury, or emergency? Call 911 if anyone is in danger, then call Comeryx at (833) 410-3738. Filling out this form does not replace any required call to a regulatory agency.

Use this form for pollution liability claims, together with the Spill or Pollution Incident Claim Form. Each witness fills out their own statement. For a General Liability claim, use the GL claim form instead.

Thank you for helping us understand this incident so that we can help prevent someone from getting hurt, property from being damaged, or a release from occurring in the future. Please describe only what you personally saw, heard or did, in your own words. Accuracy is more important than detail; if you are not sure about something, say so.

Claim reporting information

Gallagher Bassett, the claims administrator, needs this on every report.

GB Client Number042107

Client NameComeryx Insurance Services, Inc.

Date the insured was notified* (required)

State where the incident occurred* (required)

Client location

Policy Holder Business Name and DBA* (required)

Location state* (required)

Incident

Detailed description of incident* (required)0 / 250

Involved party

Involved party first name* (required)The person who was injured or whose property was damaged.

Involved party last name* (required)

Claim contact

Contact first and last name* (required)Who the adjuster should contact about this claim.

Contact phone* (required)

General information

Witness name* (required)

Position / job title

Employer

Phone number* (required)

Date of this statement

Relationship to named insured

EmployeeSubcontractorClient / OwnerOther bystander

Worksite / project name

Named insured* (required)

Worksite address

Incident date* (required)

Incident time

Type of incident

Bodily injuryProperty damageSpill / releaseNear missOther

Did you personally see or hear the incident occur?

YesNo

What you saw and heard, in chronological order

1. Where were you, and what were you doing, just before the incident?

2. What did you see and hear when the incident occurred? Describe what happened step by step.* (required)

3. What did you and others do immediately after the incident (first aid, shutting off equipment, containing a spill, calling for help)?

Additional questions

4. What was the condition of the tools, equipment, machinery, vehicles, containers and materials involved in the incident? Did anything appear damaged, worn, leaking or out of place before it happened?

5. What was the work environment like? Was it hot or cold, wet, slippery, windy, dark, noisy, or crowded? Were there any unusual odors, fumes or warnings?

6. What type and condition of personal protective equipment (PPE) was being used by the person involved when the incident occurred?

7. What instruction or training had you and others received on the task being performed when the incident occurred? Describe the training you received.

8. What was the direction of travel, fall, flow or final resting place of the vehicle, equipment, material or person involved in the incident?If a diagram helps, draw it and attach a photo of it to your email.

9. Who else witnessed or heard the incident? Please provide names, employers and contact information if you know them.

10. How do you think an incident like this could be prevented in the future?

Statement taken byFor the person taking the statement

Statement taken by

Name and title

Date

Certification

I certify that this statement is true and accurate to the best of my recollection.* (required)

Printed name* (required)

Date* (required)

The downloaded PDF includes a signature line if a signed copy is needed.

The AI-Native MGA for Small Business Artisan Contractors E&S Insurance.

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