..................................................... 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
........................................................................................................................................
PESEL.................................. NIP.............................................
Dokument tożsamości ( dowód osobisty lub paszport )
........................................................................................................................................
/ rodzaj dokumentu, seria i numer ?
zamieszkały /a/:..............................................................................................................
........................................................................................................................................
/ podać dokładny adres /
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
…………………………………….
/podpis/
*niepotrzebne skreślić