Automobile Accident Report Page 2
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3Vehicle 1
Driver Name
Description of Damage
Your Vehicle
Driver’s License Number
Vehicle Year
Vehicle Make/Model
Is the vehicle drivable?
Yes
No. If no, please provide “towed to” garage name and telephone.
Vehicle Identification Number (VIN)
_________________________________________________
Vehicle 2
Driver Name
Description of Damage
Driver’s License Number
Vehicle Year
Vehicle Make/Model
Is the vehicle drivable?
Yes
No. If no, please provide “towed to” garage name and telephone.
Vehicle Identification Number (VIN)
_________________________________________________
Insurance Company
Policy Number
Other Vehicles
Please provide detailed information for any other vehicles and drivers involved in the accident.
Police
City Police or CHP
Police Report Number
Witnesses
Witness 1 Name, Address and Telephone
Witness 2 Name, Address and Telephone
Witness 3 Name, Address and Telephone
Witness 4 Name, Address and Telephone
Arthur J. Gallagher & Co. Insurance Brokers of California, Inc.
3697 Mt. Diablo Blvd.
Tel (925) 299 1112
Auto Accident Report
Lafayette, CA 94549
Fax (925) 299 0328
Page 2
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Parent category: Business