I, the undersigned witnessed or am reporting the injury by personal observation or reported by the listed
witness, and I do hereby affirm that each and every declaration I’ve made in the above-referenced report of
injury or illness is true and correct to the best of my ability. I further affirm I have made the declarations
of my own free will, without coercion, promises or enticements of any type. I voluntarily present this
information, and with this authorization, hold harmless any recipient of the information who uses or shares the
information in any way. I know that any falsification of information herein may result in a criminal matter and
that any person who knowingly presents a false statement for the fraudulent payment of a loss is guilty of a
crime, and may be subject to fines and confinement in a state prison.