..................................................... Lublin, dnia...........................

( podać nazwę komórki organizacyjnej )

O Ś W I A D C Z E N I E

(poszkodowanego, świadka)*

wypadku w drodze z pracy lub do pracy*

Ja niżej podpisany /a/ imię i nazwisko

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PESEL.................................. NIP.............................................

Dokument tożsamości ( dowód osobisty lub paszport )

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/ rodzaj dokumentu, seria i numer ?

zamieszkały /a/:..............................................................................................................

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/ podać dokładny adres /

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…………………………………….

/podpis/

*niepotrzebne skreślić