Are you familiar with Form Mv104? If not, you should be. This is the form that businesses use to file their annual reports with the state of Vermont. It's important to fill out this form accurately and on time, or you could face penalties. In this blog post, we'll go over everything you need to know about Form Mv104. We'll explain what information is required on the form, and we'll also provide some helpful tips on how to complete it.
Below are some particulars about form mv104. Our suggestion is that you read this information before you start editing the PDF.
Question | Answer |
---|---|
Form Name | Form Mv104 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | civilian accident report, dmv accident report, dmv form mv 104, dmv mv 104 |
|
|
|
|
|
FOLD |
|
|
|
|
|
|
|
|
|
HERE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||
|
|
Use only for accidents that |
|
|
|
|
New York State Department of Motor Vehicles |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||||||||||||||||||||
|
|
|
|
REPORT OF MOTOR VEHICLE ACCIDENT |
|
|
|
|
|
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
happen in New York State |
|
|
|
|
|
|
|
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
www.dmv.ny.gov |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
BEFORE COMPLETING THIS FORM, READ THE INSTRUCTIONS IN SECTION A ON PAGE 2 |
|
|
|
|
|
|
|
|||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
DO NOT FORGET |
|
Page _______ of _______ |
o RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
ACCIDENT DATE |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
Accident Date |
Day of Week |
Time |
|
o AM |
Number of |
|
Number |
|
Number |
|
Did police investigate |
If “Yes”, Name of Police Agency or Precinct & Accident Number |
||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
Month |
|
|
Day |
|
Year |
|
|
|
|
|
|
|
Vehicles |
|
Injured |
|
Killed |
|
accident at scene? |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
o PM |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
o Yes |
o No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
DRIVER OF VEHICLE 1 |
|
|
|
|
|
|
|
|
|
|
o VEHICLE 2 |
|
o PEDESTRIAN |
|
|
oBICYCLIST |
o OTHER PEDESTRIAN |
||||||||||||||||||||||||||||||||||||||||
❶ Driver License ID Number |
|
|
|
|
|
|
|
|
|
|
|
|
State of License |
Driver License ID Number |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
State of License |
||||||||||||||||||||||||||||||||||||
|
|
Driver |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||
DRIVER |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
City or Town |
|
|
|
|
|
|
|
|
|
|
|
|
|
State |
Zip Code |
|
|
City or Town |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
State |
|
Zip Code |
Apt. Number |
||||||||||||||||||||
|
|
Address (Include Number & Street) |
|
|
|
|
|
|
|
|
Apt. Number |
Address (Include Number & Street) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Date of Birth |
|
|
|
|
|
|
|
|
|
Sex |
|
Number of |
|
|
|
Public |
|
|
Date of Birth |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Sex |
|
|
|
|
|
|
Number of |
|
|
|
Public |
|||||||||||||||||||||
|
|
Month |
|
Day |
Year |
|
|
|
People in |
|
|
|
|
Property |
|
|
|
Month |
Day |
|
|
|
Year |
|
|
|
|
|
|
|
|
|
People in |
|
|
|
Property |
|||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Vehicle |
|
|
|
|
Damagedo |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Vehicle |
|
|
|
Damagedo |
|||||||||||||
❷ |
|
|
Date of Birth |
|
|
|
|
|
|
Sex |
|
|
|
|
|
|
|
|
|
|
|
|
Date of Birth |
|
|
Sex |
||||||||||||||||||||||||||||||||||||||||||
REGISTRANT |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Month |
Day |
|
|
|
Year |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Month |
|
Day |
|
Year |
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Address (Include Number & Street) |
|
|
|
|
|
|
|
|
Apt. Number |
Address (Include Number & Street) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Apt. Number |
|||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
City or Town |
|
|
|
|
|
|
|
|
|
|
|
|
|
State |
Zip Code |
|
|
City or Town |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
State |
|
Zip Code |
|||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
Plate Number |
|
State of Reg. |
|
Vehicle Year & Make |
Vehicle Type |
|
Ins. Code |
Plate Number |
|
|
|
|
|
|
|
State of Reg. |
|
Vehicle Year & Make |
Vehicle Type |
|
Ins. Code |
|||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
¸ |
|
Estimated Cost of Property Damage - Vehicle 1 |
|
|
|
|
|
|
|
|
|
|
|
|
|
Estimated Cost of Property Damage - Vehicle 2 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||||||||||||||
|
|
o |
|
|
o |
|
o Over $2,500 |
|
|
|
o |
|
|
|
|
|
|
|
o |
|
|
o Over $2,500 |
||||||||||||||||||||||||||||||||||||||||||||||
DAMAGE |
Describe damage to vehicle 1 |
ACCIDENT DIAGRAM: Circle one of the 9 diagrams (numbered |
|
Left Turn |
|
|
Rear End |
|
Sideswipe |
|
Describe damage to vehicle 2 |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
describes the accident, or draw your own diagram below in space #9. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(same direction) |
|
|
|
|
|
|
|
|
||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
Number the vehicles. Your vehicle is # 1 |
|
|
|
|
|
|
|
|
|
|
|
|
0. |
|
|
|
|
|
1. |
|
|
|
|
|
|
|
|
2. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Left Turn |
|
|
|
Right Angle |
|
Right Turn |
|
|
|
|
|
|
|
|
|||||||||||||||||||||
VEHICLE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
3. |
|
|
|
|
|
4. |
|
|
|
|
|
|
|
|
5. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Right Turn |
|
|
|
Head On |
|
Sideswipe |
|
|
|
|
|
|
|
|
|||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
9. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(oppositedirection) |
|
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
6. |
|
|
|
|
|
7. |
|
|
|
|
|
|
|
|
8. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
¹Place Where Accident Occurred in New York State:
|
LOCATION |
County ______________________ |
o City o Village o Town |
of __________________________________. |
Permanent Landmark___________________ |
|||||||||||||||||||||||||
|
Road on which accident occurred _____________________________________________________________________________________________________________ |
|||||||||||||||||||||||||||||
|
|
|
|
|||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(Route Number or Street Name) |
|
|
|
|||||
|
|
|
|
at o1)intersectingstreet______________________________________________________________________________________________________________________ |
||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
o N |
o S |
|
|
|
|
|
|
|
|
|
|
(Route Number or Street Name) |
|
|
|
||||||
|
|
|
|
or |
2) __________ __________ |
|
of ______________________________________________________________________________________ |
|||||||||||||||||||||||
|
ACCIDENT |
|
o E |
o W |
||||||||||||||||||||||||||
|
|
|
Feet |
Miles |
|
|
|
|
|
|
|
|
|
|
|
|
|
(Milepost, Nearest intersecting Route Number or Street Name) |
|
|
|
|||||||||
|
|
|
|
How did the accident happen? |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
8. Which Veh. |
9. Position |
|
10. Safety |
|
12. |
|
13. |
16. Injury |
|
|
|
|
|
If Deceased, Enter |
|||||||
|
|
|
|
|
Names of All Persons Involved |
|
Occupied |
|
in/on Vehicle |
Equip.Used |
Age |
|
Sex |
A |
B |
C |
|
Describe Injuries |
|
Date of Death |
||||||||||
ALL INVOLVED |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
‘ Identify Damaged Property |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
VIN |
|
|
|
||||||
|
|
|
|
Other Than Vehicle(s) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
INSURANCE |
|
|
Name of Insurance Company |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Policy |
|
|
|
||
|
|
|
|
That Issued Policy For Vehicle 1 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Number |
|
|
|
|||
|
|
|
|
Name and Address of |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Policy Period |
|
|
|
||
|
|
|
|
Policy Holder |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
From |
To |
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
If Vehicle was Operated Under Permit |
|
|
|
|
|
|
|
Name and Address |
|
|
|
|
|
|
|
|
|
|||||||||
|
|
|
|
(ICC, USDOT or NYSDOT), give No. |
|
|
|
|
|
|
|
of Permit Holder |
|
|
|
|
|
|
|
|
|
|||||||||
|
|
|
|
If |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
and State |
|
|
|
||
|
|
|
|
Certificate No. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
Date |
|
|
Print Name of Driver |
|
|
|
|
|
|
|
|
|
|
|
|
Signature of Driver |
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
(or Representative*) |
|
|
|
|
|
|
|
|
|
|
|
|
(or Representative*) ç |
|
|
|
|
|
|
|||||
|
|
|
|
|
|
of Vehicle 1 |
|
|
|
|
|
|
|
|
|
|
|
|
|
of Vehicle 1 |
|
|
|
|
|
|
|
|||
|
A representative may sign for the driver if the driver is unable to sign |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||
because* |
ofinjuryordeath.Ifyouaresigningasthedriver’srepresentative, |
oInjury |
|
|
An accident report is not considered complete and filed unless it is signed, |
|
||||||||||||||||||||||||
checktheboxthatdescribeswhythedrivercannotsign. |
|
|
|
oDeath |
|
|
and if not signed may result in the suspension of your driver’s license. |
|
||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1
2
3
4
5
6
7
23
24
25
26
27
28
29
30
You must report within 10 days any accident occurring in New York State causing a fatality, personal injury or damage over $1,000 to the property of any one person. Failure to do so within 10 days is a misdemeanor. Your license and/or registration may be suspended until a report is filed. Check the “RUSH” box at the top of page 1 if your license is suspended for failuretoreportthisaccidentontime.You must fill in all information requested on the report.
Then fill in the boxes numbered
* First — fold along this shaded, dotted line.*
*Don’t fold internetform. Instead, place page 2 over page 1, with the arrows on page 2 pointing to the boxes on the right edge of page 1.
•
•
•avehicleotherthanamotorvehicle
•an unoccupied vehicle, enter all available information. Be sure to enter the correct vehicle Plate Number and Vehicle Type in the VEHICLE 2 block.
•more than two vehicles, fill out additional accident reports. On these reports, place the informationforthethirdvehicleinthespacemarkedVEHICLE1andmarkit#3.Usethe spacemarkedVEHICLE2forthefourthvehicle,andmarkit#4andsoon.Additionalforms areavailableatanyMotorVehiclesofficeorfromtheDMVwebsite:www.dmv.ny.gov.
❶
❷REGISTRANT - Enter registrant information EXACTLY as it appears on the registration of each vehicle involved in the accident.
¸VEHICLE DAMAGE - Indicate if the accidentexceedsthe$1,000thresholdforpropertydamage toanyonevehicleorpropertycausedbytheaccident,anddescribethevehicledamage.
¹ACCIDENT LOCATION - Enter the county, locality and street(s) where the accident occurred. Check the box if there is an intersecting street. If available, identify a permanent landmark nearby, such as a business, school, shopping mall, parking lot, water tower, railroad, mountain or cell tower.
ºALL INVOLVED - List the names of all persons involved in the accident, and provide the date of death if anyone was killed in, or as a result of, the accident. If more than four people are involved, complete another report. In the ALL INVOLVED section of that report, provide the required information for everyone else involved in the accident. Enter the following codes in the appropriate columns:
WHICH VEHICLE OCCUPIED (Column8) - Enter the appropriate number or letter.
1. Vehicle 1 |
2. Vehicle 2 |
B. Bicyclist |
P.Pedestrian |
|
O. OtherPedestrian |
|||||||
POSITION IN/ON VEHICLE (Column9) |
|
|
8 |
|
|
|||||||
diagram which corresponds to each person’s position. |
|
|
|
|
|
|
||||||
|
|
|
4 |
|
1 |
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
||
1. Driver |
|
8. Riding/Hanging on Outside |
8 |
7 |
|
5 |
|
2 |
|
8 |
||
|
|
|
|
|
|
|
|
6 |
|
3 |
|
|
SAFETY EQUIPMENT USED (Column10) |
|
|
|
|
|
8 |
|
|
||||
|
|
|
|
|
|
|
|
|
||||
1. None |
|
7. AirBagDeployed |
|
|
|
|||||||
2. Lap Belt |
|
8. AirBagDeployed/LapBelt |
|
|
C.Helmet Only |
|
||||||
3. Shoulder Restraint |
9. AirBagDeployed/ShoulderRestraint |
|
||||||||||
4. LapBeltRestraint |
A. AirBagDeployed/LapBelt/Restraint |
D.Helmet/Other |
|
|||||||||
5.ChildRestraintOnly |
B. AirBagDeployed/ChildRestraint |
|
|
E.Pads Only |
|
|||||||
6.Helmet(MotorcycleOnly) O. Other |
|
|
|
F.Stoppers Only |
||||||||
|
|
|
|
|
|
|
|
|
||||
|
||||||||||||
injuries, unconscious when taken from the accident scene, unable to leave accident |
||||||||||||
scene without assistance. |
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
||||
|
||||||||||||
injury),whiplash(complaintofneckandheadpain). |
|
|
|
|
|
|
|
|
‘
Attach additional reports to page one. Each page of the report must be numbered in the upper left corner. Mark additional sheets #2, #3, etc. Date and sign on the bottom line of each attached report.
OR SHE IS UNABLE TO SIGN BECAUSE HE/SHE IS INJURED OR DECEASED.
Sendoriginal to: CRASH RECORDS CENTER 6 EMPIRE STATE PLAZA PO BOX 2925 ALBANY NY
|
|
SECTIONB |
|
|
Besureyour |
|||||||
|
|
|
answersaremarked |
|||||||||
|
|
|
USETOCOMPLETE |
|
|
INSIDETHE |
||||||
|
|
|
|
BOXES ON |
||||||||
PEDESTRIAN/BICYCLIST/OTHER PEDESTRIAN LOCATION |
PAGE |
|||||||||||
1. Pedestrian/Bicyclist/Other Pedestrian at Intersection |
1 |
|||||||||||
|
||||||||||||
2. Pedestrian/Bicyclist/Other Pedestrian Not at Intersection |
|
|||||||||||
PEDESTRIAN/BICYCLIST/OTHER PEDESTRIAN ACTION |
1 |
|||||||||||
|
||||||||||||
1. Crossing, With Signal |
|
|
|
|
|
|
|
|||||
2. Crossing, Against Signal |
|
|
|
|
|
|
||||||
3. Crossing, No Signal, Marked Crosswalk |
|
|
|
|
||||||||
4. Crossing, No Signal or Crosswalk |
|
|
|
|
||||||||
5. Riding/Walking/Skating Along Highway With Traffic |
|
|
||||||||||
6. Riding/Walking /Skating Along Highway Against Traffic |
2 |
|||||||||||
7. Emerging from in Front of/Behind Parked Vehicle |
|
|||||||||||
|
|
|||||||||||
8. Going to/From Stopped School Bus |
|
|
|
|
||||||||
9. Getting On/Off Vehicle Other Than School Bus |
|
|
||||||||||
11. Working in Roadway |
|
|
|
|
|
|
|
|||||
12. Playing in Roadway |
|
|
|
|
|
|
|
|||||
13. Other Actions in Roadway |
|
|
|
|
|
|||||||
14. Not in Roadway |
|
|
|
|
|
|
|
|||||
TRAFFIC CONTROL |
|
10. RR Crossing Gates |
|
|||||||||
1. |
None |
|
|
|
|
|
||||||
2. |
Traffic Signal |
|
|
11. Stopped School |
|
|||||||
3. |
Stop Sign |
|
|
|
|
Lights Flashing |
|
|||||
4. |
Flashing Light |
|
|
12. Construction Work Area |
|
|||||||
5. |
Yield Sign |
|
|
|
13. Maintenance Work Area |
3 |
||||||
6. |
Officer/Guard |
|
|
14. Utility Work Area |
|
|
||||||
7. |
No Passing Zone |
|
15. Police/Fire Emergency |
|
||||||||
8. |
RR Crossing Sign |
|
16. School Zone |
|
|
|||||||
9. |
RR Crossing Flashing Light 20. Other |
|
|
|
|
|||||||
LIGHT CONDITIONS |
|
|
|
|
|
|
|
|||||
1. |
Daylight |
|
|
3. Dusk |
|
4 |
||||||
2. |
Dawn |
|
|
4. |
|
|
|
|
||||
ROADWAY CHARACTER |
|
|
|
|
|
|
||||||
1. |
Straight and Level |
|
|
4. Curve and Level |
5 |
|||||||
2. |
Straight and Grade |
|
|
5. Curve and Grade |
||||||||
|
|
|
||||||||||
3. |
Straight at Hillcrest |
|
|
6. Curve at Hillcrest |
|
|||||||
ROADWAY SURFACE CONDITION |
|
|
|
|
||||||||
1. |
|
Dry |
3. |
Muddy |
|
5. |
Slush |
|
0. |
Other |
6 |
|
2. |
|
Wet |
4. |
Snow/Ice |
6. |
Flooded |
|
|
|
|
||
WEATHER |
|
2. Cloudy |
5. |
Sleet/Hail/Freezing Rain |
|
|||||||
1. Clear |
|
3. Rain |
|
6. Fog/Smog/Smoke |
|
7 |
||||||
|
4. Snow |
|
0. Other |
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
||||
DIRECTION OF TRAVEL |
|
|
|
|
|
|
|
|||||
|
NW |
N |
|
NE |
|
|
|
|
|
|
Veh. |
|
|
1 |
|
1. |
North |
5. |
South |
|
1. 23 |
||||
|
|
8 |
2 |
|
2. |
Northeast |
6. |
Southwest |
|
|||
W |
7 |
|
3 |
E |
3. |
East |
|
7. |
West |
|
|
|
|
|
6 |
5 |
4 |
|
4. |
Southeast |
8. |
Northwest |
Veh. |
||
SW |
|
SE |
|
|
|
|
|
|
2 24 |
|||
|
|
|
|
|
|
|
|
|||||
|
|
|
S |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||
1. Going Straight Ahead |
|
11. AvoidingObjectinRoadway |
|
|||||||||
2. Making Right Turn |
|
12. Changing Lanes |
|
Veh. |
||||||||
3. Making Left Turn |
|
13. Passing |
|
|
|
1 25 |
||||||
4. Making U Turn |
|
14. Merging |
|
|
|
|
||||||
5. Starting from Parking |
|
15. Backing |
|
|
|
|
||||||
6. Starting in Traffic |
|
16. Making Right Turn on Red |
|
|||||||||
7. Slowing or Stopping |
|
17. Making Left Turn on Red |
Veh. |
|||||||||
8. Stopped in Traffic |
|
18. Police Pursuit |
|
2 26 |
||||||||
9. EnteringParkedPosition |
20. Other |
|
|
|
|
|||||||
10. Parked |
|
|
|
|
|
|
|
|
|
|
||
LOCATION OF FIRST EVENT |
|
|
|
|
27 |
|||||||
|
|
1. On Roadway |
|
2. Off Roadway |
|
|
||||||
|
|
|
|
|
|
|||||||
TYPE OF ACCIDENT |
|
|
|
|
|
|
|
|||||
|
|
|
|
|
COLLISION WITH |
|
|
|
|
|||
1. Other Motor Vehicle |
|
6. |
|
First |
||||||||
2. Pedestrian |
|
|
|
7. Deer |
|
|
|
28 |
||||
3. |
Bicyclist |
|
|
|
|
8. Other Pedestrian |
|
Event |
||||
|
|
|
|
10. Other Object (Not Fixed) |
|
|||||||
4. Animal |
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|||
5. Railroad Train |
|
|
|
|
|
|
|
|||||
|
|
|
COLLISION WITH FIXED OBJECT |
|
|
|||||||
11. Light Support/Utility Pole |
21. Median - Not At End |
|
||||||||||
12. Guide Rail - Not At End |
22. Snow Embankment |
|
|
|||||||||
13. Crash Cushion |
|
23. Earth Embankment/ |
Veh.29 |
|||||||||
14. Sign Post |
|
|
|
|
Rock Cut/Ditch |
|
1 |
|||||
15. Tree |
|
|
|
|
24. Fire hydrant |
Second |
|
|||||
16. Building/Wall |
|
|
25. Guide Rail - End |
Event |
|
|||||||
17. Curbing |
|
|
|
|
26. Median - End |
|
|
Veh. |
||||
18. Fence |
|
|
|
|
27. Barrier |
|
|
|
||||
|
|
|
|
|
|
|
2 30 |
|||||
19. Bridge Structure |
|
30. Other Fixed Object |
|
|||||||||
20. Culvert/Head Wall |
|
|
|
|
|
|
|
|||||
|
|
|
|
|
NO COLLISION |
|
|
|
|
|||
31. Overturned |
|
|
|
33. Submersion |
|
|
|
|||||
32. Fire/Explosion |
|
34. Ran Off Roadway Only |
|
|||||||||
|
|
|
|
|
|
|
40. Other |
|
|
|
|