Statement Form

Interview Information

Interview with:

Date obtained: 11/7/2025

Personal Info updated:

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OFF RECORDING

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Were you using your own credentials at the time of loss?
If no, whose credentials were you using?
How and when was permission given?
Frequency of use of those credentials?

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TNC

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Uber entity:
Accepted ride? Passenger or food in vehicle?
Other rideshare or delivery apps used:
Vehicle used for taxi/limo services:
Optional injury coverage purchased:
Vehicle owner:
Insurance on vehicle:
Rideshare endorsement:
Other policies for driver/vehicle:

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PERIOD QUESTIONS

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How many riders:
Seating locations:
Wearing seatbelts:
Did the riders indicate injury:
PORTIER - Carrying goods? Damaged?:

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PAP Rideshare Questions

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PAP RIDESHARE QUESTIONS

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Were you active doing rideshare or delivery at the time?
IF RIDESHARE DISPUTED: Where were you coming from and going to?
IF RIDESHARE DISPUTED: were you logged into a rideshare app at any time during that day? When and where did you log out?
What company?
Were you using your credentials or someone else's? Whose?
What was your status in the app(logged in/en route to pickup/rider or delivery in vehice)?
Have you reported a claim to that company? (obtain claim info)
Are any other vehicles on your policy used for rideshare or delivery?
DELIVERY: What store or restaurant were you headed to/picked up from:
DELIVERY: What products were in your vehicle at the time of loss:

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General Statement

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LOSS

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Loss date/time:
Injured:
Seatbelt:
Carseats:
Police/Citations:
Witnesses:
Loss Location:
Direction:
Traffic Controls:
Speed/PSL:

Intersection

Distance from intersection when first saw light/stop sign:
LIGHT: what color was the light as you approached:
If stopped, for how long:
Were there any other vehicles stopped at the intersection:
LIGHT: what did you do when the light turned green:

Pedestrian

What part of pedestrian struck car:
What part of car struck pedestrian:
Was the pedestrian bleeding or have visible injuries:
Was there blood at the scene:
Did they claim any specific injuries at the scene:
Describe the pedestrian. What were they wearing:
Ambulance come to scene? Transported?

Door Opening - Vehicle that Struck Door

PARKING - Which direction were you turning to park:
PARKING - Were spaces straight or angled:
PARKING - Was the aisle one way or two way:
PASSING - How close were you to the parked vehicle:
When did you first see the door open:
Who opened the door:
How far open was the door when impact occurred:
How long was the door open:

Door Opening - Vehicle with Door Struck

PARKING - Were spaces straight or angled:
PARKING - Were the spaced clearly marked:
PARKING - Which direction was the vehicle turning to park:
Who opened the door:
How did the party opening the door make sure it was clear:
How far open was the door when impact occurred:
How long was the door open:

FOL:

Signals:
Weather:
First saw other vehicle:
Evasive actions:
IV POI/Damages:
CV POI/Damages:
Photos/Video:
Dashcam:

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Rider Statement

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RIDER STATEMENT

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Personal info updated:
Loss date/time:
Injured:
Seating Location:
Seatbelt:
Loss Location:
Traffic Controls:
FOL:

Evasive Action:
IV POI/Damages:
CV POI/Damages:
Photos/Video:

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No Contact - Driver

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NO CONTACT

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Loss date/time:
Injured:
Seatbelt:
Carseats:
Police/Citations:
Witnesses:

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Remember Ride?
Pickup Location:
Incidents/Conversation at pickup:
How many riders/seating:
Description of riders:
Incidents/Accidents/Location:

Any rider injuries noted:
Drop Location:
Incidents/Conversation at drop:

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IV POI/Damages:
CV POI/Damages:
Photos/Video:
Dashcam:

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No Contact - Rider

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NO CONTACT

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Loss date/time:
Injured:
Seatbelt:

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Pickup Location:
Incidents/Conversation at pickup:
How many riders/seating/info:
Description of riders:
Description of vehicle:
Incidents/Accidents/Location:

Drop Location:
Incidents/Conversation at drop:

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IV POI/Damages:
CV POI/Damages:
Photos/Video:

Injury Statement

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INJURY EVAL

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Personal Info Obtained:
Married:
Seatbelt:
Preferred Arm/Hand:
Injury:

Pain level:
Mechanism:
Treatment to date:
Treatment planned:
OOP Expense:
Health Insurance:
Medicare/Medicaid(Medi-cal):

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Currently Employed/Occupation:
Any days Missed/Doctor's Note:
Employer Info:

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Impact on Lifestyle:
Prior injury:
Offer?

TNC Recorded Release

Claimant Lastname

UW Company

Driver Name

Owner Name

Settle Amount

$

This is , from .

Today's date is November 7, 2025, and I am speaking by telephone to concerning an automobile accident that took place on at involving and , who was insured by .

The purpose of this recorded statement is to confirm the settlement terms regarding 's bodily injury claim against and Uber Technologies, Inc, also referred to as Uber, and it's subsidiaries.

Please state your full name and address.

Mr./Ms. , do you realize that I am recording this conversation?

And do I have your permission to do so?

What is your date of birth?

You are presenting a claim for bodily injuries from the auto accident on at , is that correct?

We have been discussing settlement of your claims and we have reached the following agreement.

I have offered to you and you have accepted the sum of $ in full and final settlement of your claims. This amount includes and accounts for all related medical expenses, pain and suffering, lost wages, and any and all other alleged damages that you have incurred or might incur in the future as a result of this accident on .

Do you understand that by agreeing to this settlement and accepting payment, you agree to release Uber and it's subsidiaries, , and all of their respective past, present or future related entity, person, insurer, or company in full, and are waiving all rights to file a lawsuit or make any further claims against them as a result of the accident on ?

Do you understand that by agreeing to this settlement and accepting payment, you agree that the terms of this agreement and the settlement amount are strictly confidential, and you will not disclose them to any individual or entity, nor will you disparage Uber and its subsidiaries in the future?

I want to confirm that you have had the opportunity to consider this settlement agreement to the extent you wish to do so?

Are you in agreement that this is a fair resolution of your claims and that you are entering into this settlement of your own free will?

Do you agree that the payment I am sending in the amount of $ is the full, final and complete settlement of your claims against Uber and it's subsidiaries, and , resulting from the accident on ?

Thank you. I am now turning off the recorder.

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Wrap Up

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WRAP UP

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Vehicle Location:
Repairs:
Discussion:
Expectation: