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This is an example of a completed statement of claim in order to recover money following a car accident. PART 1: Fill in all blanks with the information requested.The short answer is that a written statement is the best option in almost every circumstance. A. Your insurance company will contact you for detailed information regarding the loss and may take a a written or recorded statement. This packet must be used only if your case involves a motor vehicle accident, and you want to file a complaint in Small Claims Court. This is an overview of how to complete the SC50 Small Claims Statement of Claim form. This is not intended to be an exhaustive or complete recitation of the law. Please forward an estimate for the damage, a copy of the declaration sheet from your insurance policy, and complete the enclosed Tort claim form. As noted above, the first step is to fill out the Statement of the Claim form. Second, you need to notify the defendant.