NOTE: Susie's Mopeds does not accept paper waivers, please submit electronically.

Witness &/or Injured Persons Statement of Accident

CDA Claims Direct Access

8722 S Harrison St. Sandy, UT 84070

877-585-2849 CDA@Primeis.com

Our insurance company asks us to collect witness statements pertaining to accidents so they may determine how these accidents occur. Please provide the information requested below as completely as possible. Thank you for your assistance in this very important matter.

Name of Insured: Island Wheels, LLC. Policy No. SC24062486

Your Full Name

Address

City

State

Zip Code

Phone Number

Email Address

Please describe events leading up to the accident.

Please describe the accident.

Describe what happened after the accident took place.

Can you think of any way this type of accident could be avoided in the future?

Were sufficient warnings, instructions, and information provided?

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Signature

Wed Apr 2, 2025

NOTE: Susie's Mopeds does not accept paper waivers, please submit electronically.

Witness &/or Injured Persons Statement of Accident

Z. CDA Witness Statement