Automobile Accident Report Page 3
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1
2
3Injury 1
Name
Nature of Injury
Address
Taken to hospital?
No
Yes. If yes, please provide hospital name
_________________________________________________
Telephone
Injury Occurred
Vehicle 1
Vehicle 2
Pedestrian
Other. Please specify ___________________
___________________________________
Injury 2
Name
Nature of Injury
Address
Taken to hospital?
No
Yes. If yes, please provide hospital name
_________________________________________________
Telephone
Injury Occurred
Vehicle 1
Vehicle 2
Pedestrian
Other. Please specify ___________________
___________________________________
Other Injuries
Please provide detailed information for any other injuries.
Additional
Comments
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 3
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