Form Mv104 PDF Details

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.

QuestionAnswer
Form NameForm Mv104
Form Length2 pages
Fillable?Yes
Fillable fields161
Avg. time to fill out32 min 46 sec
Other namesnys motor vehicle, mv104, mv 104 form, dmv mv 104

Form Preview Example

 

 

 

 

MV-104 (5/11) PAGE 1 of 2

 

 

 

 

 

FOLD

 

 

 

 

 

 

 

 

 

 

 

 

 

HERE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New York State Department of Motor Vehicles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Use only for accidents that

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 _______

 

RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT

 

 

 

 

ACCIDENT DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accident Date

 

Day of Week

 

Time

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?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER OF VEHICLE 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE 2

PEDESTRIAN

 

 

 

BICYCLIST

 

OTHER PEDESTRIAN

 

0

Driver License ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State of License

Driver License ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State of License

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver Name–exactly as printed on license (Last, First, M.I.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name–exactly as printed on license (Last, First, M.I.)

 

 

 

 

 

 

 

 

 

 

 

 

 

<![endif]>DRIVER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City or Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

Zip Code

 

 

 

 

City or Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

Zip Code

 

 

 

 

 

 

 

Address (Include Number & Street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt. Number

Address (Include Number & Street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt. Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

Damaged

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle

 

 

 

 

 

 

 

Damaged

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

@

 

Name–exactly as printed on registration

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

Sex

Name–exactly as printed on registration

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

Sex

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

 

Day

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

 

Day

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

<![endif]>REGISTRANT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$1,001-$1,500

 

 

 

$1,501-$2,500

 

 

 

 

 

 

 

Over $2,500

 

 

 

 

 

 

$1,001-$1,500

 

 

 

 

 

 

 

 

$1,501-$2,500

 

 

 

 

 

 

Over $2,500

 

 

<![endif]>DAMAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe damage to vehicle 1

ACCIDENT DIAGRAM: Circle one of the 9 diagrams (numbered 0-8) if it

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

<![endif]>VEHICLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Right Turn

 

 

 

Head On

Sideswipe

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(opposite direction)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

7.

 

 

 

 

 

 

 

 

 

8.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0

Place Where Accident Occurred in New York State:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Permanent Landmark___________________

 

 

<![endif]>LOCATION

County ______________________

 

 

City

Village

Town

 

of __________________________________.

 

 

 

 

 

Road on which accident occurred _____________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Route Number or Street Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

at

1) intersecting street______________________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Route Number or Street Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or

2) __________ __________

 

 

 

 

 

 

 

______________________________________________________________________________________

 

 

<![endif]>ACCIDENT

 

 

 

E

 

W

of

 

 

 

 

 

 

 

Feet

 

Miles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Milepost, Nearest intersecting Route Number or Street Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How did the accident happen?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

<![endif]>ALL INVOLVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

 

Identify Damaged Property

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

<![endif]>INSURANCE

Other Than Vehicle(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 Self-Insured, give

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certificate No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

Print Name of Driver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Driver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(or Representative*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(or Representative*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of Vehicle 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of Vehicle 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A representative may sign for the driver if the driver is unable to sign

 

 

 

 

Injury

 

 

An accident report is not considered complete and filed unless it is signed,

 

because*

of injury or death. If you are signing as the driver’s representative,

 

 

 

 

 

 

 

 

 

 

and if not signed may result in the suspension of your driver’s license.

 

check the box that describes why the driver cannot sign.

 

 

 

 

 

 

 

 

 

 

 

Death

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

3

4

5

6

7

23

24

25

26

27

28

29

30

reset/clear

THE REPORT MUST BE SIGNED BY THE DRIVER OF VEHICLE 1, UNLESS HE

MV-104 (5/11) PAGE 2 of 2

SECTION A

 

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 failure to report this accident on time. You must fill in all information requested on the report.

Then fill in the boxes numbered 1-7 and 23-30 in the right margin on page 1 by entering the number of the item from Section B that best describes the circumstances of the accident. If a question does not apply, enter a dash (“-”). If you do not know an answer, enter an “X”.

INSTRUCTIONS - PLEASE PRINT OR TYPE ALL INFORMATION - USE BLACK INK

* First — fold along this shaded, dotted line.*

*Don’t fold internet form. Instead, place page 2 over page 1, with the arrows on page 2 pointing to the boxes on the right edge of page 1.

VEHICLE INVOLVEMENT - If you were in an accident involving:

two-cars, enter your information in the VEHICLE 1 section and the other driver’s information in the VEHICLE 2 section.

a pedestrian, bicyclist or other pedestrian (a person using a non-motorized conveyance such as in-line skates, skateboard,sled, etc.), enter the information in the “Driver” spaces provided for Vehicle 2, and check the PEDESTRIAN, BICYCLIST or OTHER PEDESTRIAN box.

a vehicle other than a motor vehicle (such as a snowmobile, mini-bike, aircycle, all-terrain vehicle, trail bike, or other non-motor vehicle), enter the driver, registrant and vehicle information in the space provided for VEHICLE 2.

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 information for the third vehicle in the space marked VEHICLE 1 and mark it # 3. Use the space marked VEHICLE 2 for the fourth vehicle, and mark it # 4 and so on. Additional forms are available at any Motor Vehicles office or from the DMV website: www.dmv.ny.gov.

0DRIVER - Enter the information for each driver EXACTLY as it appears on his/her driver license.

@REGISTRANT - Enter registrant information EXACTLY as it appears on the registration of each vehicle involved in the accident.

¸VEHICLE DAMAGE - Indicate if the accident exceeds the $1,000 threshold for property damage to any one vehicle or property caused by the accident, and describe the vehicle damage.

0 ACCIDENT 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.

0 ALL 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 (Column 8) - Enter the appropriate number or letter.

1. Vehicle 1

2. Vehicle 2

B. Bicyclist

P. Pedestrian

 

O. Other Pedestrian

POSITION IN/ON VEHICLE (Column 9) - Enter the number from this

 

 

8

 

 

diagram which corresponds to each person’s position.

 

 

 

 

 

 

 

 

 

4

 

1

 

 

1. Driver 2-7. Passengers

 

8. Riding/Hanging on Outside

8

7

 

5

 

2

 

8

SAFETY EQUIPMENT USED (Column 10)

 

 

 

 

6

 

3

 

 

 

 

 

 

 

8

 

 

 

 

 

 

In-Line Skater/Bicyclist

1. None

 

7. Air Bag Deployed

 

 

 

 

2. Lap Belt

 

8. Air Bag Deployed/Lap Belt

 

 

C.Helmet Only

 

3. Shoulder Restraint

9. Air Bag Deployed/Shoulder Restraint

 

4. Lap Belt Restraint

A. Air Bag Deployed/ Lap Belt/Restraint

D.Helmet/Other

 

E.Pads Only

 

5. Child Restraint Only

B. Air Bag Deployed/Child Restraint

 

 

 

 

 

F. Stoppers Only

6. Helmet (Motorcycle Only) O. Other

 

 

 

 

 

 

 

 

 

 

 

 

INJURY (Columns 16A-C) - Check all column(s) that apply and DESCRIBE INJURIES:

 

A - Severe lacerations, broken or distorted limbs, skull fracture, crushed chest, internal

injuries, unconscious when taken from the accident scene, unable to leave accident

scene without assistance.

 

 

 

 

 

 

 

 

 

 

B - Lump on head, abrasions, minor lacerations.

 

 

 

 

 

 

 

 

 

C - Momentary unconsciousness, limping, nausea, hysteria, complaint of pain (no visible

 

injury), whiplash (complaint of neck and head pain).

 

 

 

 

 

 

 

 

INSURANCE - Enter damage to private property, if any, insurance policy information and VIN.

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.

Send original to: CRASH RECORDS CENTER 6 EMPIRE STATE PLAZA PO BOX 2925

ALBANY NY 12220-0925

 

 

SECTION B

 

 

Be sure your

 

 

 

answers are marked

 

 

 

USE TO COMPLETE

 

 

INSIDE THE

 

 

BOXES 1-7 and 23-30 ON PAGE 1

 

 

BOXES ON

 

 

 

 

 

PAGE

PEDESTRIAN/BICYCLIST/OTHER PEDESTRIAN LOCATION

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 Bus-Red

 

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

 

5.Dark-Road Unlighted

4

2.

Dawn

 

 

4. Dark-Road Lighted

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

N

 

NE

 

 

 

 

 

 

Veh.

 

NW

1

 

1.

North

5.

South

 

1. 23

 

 

8

2

 

2.

Northeast

6.

Southwest

 

W

7

 

3

E

3.

East

 

7.

West

 

 

 

4.

Southeast

8.

Northwest

 

 

 

6

5

4

 

Veh.

 

 

 

 

 

 

 

 

 

SW

S

 

SE

 

 

 

 

 

 

2 24

 

 

 

 

 

 

 

 

 

 

 

 

PRE-ACCIDENT VEHICLE ACTION

 

 

 

 

1. Going Straight Ahead

 

11. Avoiding Object in Roadway

 

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. Entering Parked Position

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. In-Line Skater

 

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

 

 

 

 

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