The Manager
_____________ (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.

Thank you,

Signature: _____________
Your Name: __________
Mobile number: _________

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