_____________ (Company Name)
_____________ (Company Address)
Date: __/__/____ (Date)
Subject: Self Declaration regarding the accident
I, _______________ (Patient Name), son of/ daughter of/ wife of _______________ residing at ( Address) hereby confirm that I was ________ (what your were doing at the time of accident) when suddenly __________ (reason of accident) and accident took place at __________ (location where accident taken place). It was around __________ (Time) when accident took place.
I hereby declare that statement made above is true to the best of my knowledge.
I am enclosing _________ (undertaking/form/witness details) along with the application.
Your Name: __________
Mobile number: _________