Automobile Accident Report
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3Arthur J. Gallagher& Co. Insurance Brokers of California, Inc.
3697 Mt. Diablo Blvd.
After Hours Emergency Claims Pager
Lafayette, CA 94549
(800) 713 7458
Automobile Accident Report
Instructions
Please complete the form below and fax it to (925) 299 0328.
Questions? Please call (925) 299 1112 to speak with a claims specialist.
In the Event of an Accident ...
1. Contact appropriate authorities/first aid/medical assistance immediately.
Be polite, courteous and understanding with all parties. Cooperate fully with any authorities.
Refer any questions regarding further claim contact to us.
2. Do not admit fault, discuss liability, or make any commitments at the scene.
3. Take photos if possible.
4. Take all steps necessary to mitigate further damages. Maintain records and receipts for any
expenses. Do not authorize any non-emergency repairs.
5. Contact us immediately via phone, fax, after-hours pager or email
6. Start a list of all damaged/stolen property. Secure receipts/records of original as well as
any replacements.
Date and
Date Accident Occurred
City Where Accident Occurred
Location of
Accident
Time Accident Occurred
County Where Accident Occurred
Road Conditions (Wet, Construction, Lane Closed, etc.)
Road, Street or Highway
Weather Conditions (Rainy, Sunny, Snowing, etc.)
Cross Street or Nearest Exit
Indicate Any Obstructions to Driver’s View
Direction of Travel
North
East
South
West
Detailed Accident Description
Diagram of Accident (Label your vehicle as Vehicle 1.)
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Parent category: Business