MV 104 Form – Fill Out and Use This PDF

The MV-104 form is a document used by the New York State Department of Motor Vehicles (DMV) to report motor vehicle accidents. It is required for incidents within New York State involving personal injury, fatality, or property damage exceeding $1,000. This official form helps document accident details necessary for legal, insurance, and DMV purposes.

If you must complete the MV-104 form to comply with New York State regulations, click the button below.

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MV 104 Form PDF Details

When a motor vehicle accident occurs in New York State, the involved parties must fill out the MV-104 form, a document required by the DMV. This form is an official accident report and plays a key role in the administrative processing of accidents, impacting everything from insurance claims to legal proceedings.

The MV-104 form captures the date, time, location, and description of the accident, along with personal information about the drivers, vehicles involved, and any injuries or fatalities. On the second page, it highlights the significance of reporting accidents that result in personal injury, death, or property damage exceeding $1,000 within ten days, underlining the legal obligations and repercussions of non-compliance. Furthermore, it features instructions for accurately depicting the accident scene and documenting all involved vehicles and pedestrians.

Question	Answer
Form Name	MV 104 Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	104
Avg. time to fill out	15 min
Other names	MV 104 form 7 05, MV104 form, MV 104, MV 104a police accident report

Form Preview Example

MV-104 (7/05) PAGE 1 of 2

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.nysdmv.com

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

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

❶

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.)

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

Damaged !

Vehicle

Damaged !

❷

Name–exactly as printed on registration

Date of Birth

Sex

Name–exactly as printed on registration

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

❸

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

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

Left Turn

Right Angle

Right Turn

VEHICLE

Right Turn

Head On

Sideswipe

(opposite direction)

❹

Place Where Accident Occurred in New York State:

LOCATION

County ______________________

! City ! Village

! Town

of __________________________________.

Permanent Landmark___________________

Road on which accident occurred _____________________________________________________________________________________________________________

(Route Number or Street Name)

at !1) intersecting street______________________________________________________________________________________________________________________

! N

! S

(Route Number or Street Name)

2) __________ __________

______________________________________________________________________________________

ACCIDENT

! E

! 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

Describe Injuries

Date of Death

ALL INVOLVED

Identify Damaged Property

VIN

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

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

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

because*

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

! Injury

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

check the box that describes why the driver cannot sign.

! Death

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

How to Edit MV 104 Form Online for Free

The MV-104 form reports motor vehicle accidents to the New York State DMV. Completing this form accurately is very important for legal and insurance purposes. Below is a step-by-step guide on how to fill it out.

1. Gather Information

Before filling out the form, collect all necessary information regarding the accident. This covers the date, time, and location of the accident, as well as details about the vehicles, drivers, and any injuries sustained.

2. Fill Out Accident Information

Write the exact date and time of the accident. Specify the location with as much detail as possible, including the street name, the nearest cross street, and the city or town.

Stage number 1 for submitting mv 104 form

3. Vehicle Information

Provide detailed information for each vehicle involved in the accident. This includes the make, model, year, and license plate number. Additionally, indicate the extent of damage to each vehicle.

4. Driver Information

For each vehicle involved, fill in the driver’s information, including name, address, driver's license number, and insurance details. Ensure this information is accurate to avoid issues with insurance claims.

5. Diagram of the Accident

Draw a diagram of the accident scene in the space provided. Include the position of each vehicle before and after the collision, and mark the direction each was traveling.

mv 104 form writing process outlined (stage 2)

6. Description of the Accident

In the narrative section, describe the accident in detail. Include any relevant information that the diagram does not show, such as weather conditions, road quality, or any obstacles that played a role in the accident.

7. Witness Information

If there were any witnesses to the accident, provide their names and contact information. Witness accounts can be crucial in determining fault in complex accident scenarios.

Best ways to fill out mv 104 form part 3

8. Review and Sign

Review the information for accuracy. Once you know all the complete details, sign and date the form. Your signature verifies that the information is accurate to the best of your knowledge.

9. Submit the Form

Finally, submit the completed form to the DMV. Be sure to keep a copy for your records and insurance purposes.

MV 104 Form – Fill Out and Use This PDF

MV 104 Form PDF Details

Form Preview Example

How to Edit MV 104 Form Online for Free

1. Gather Information

2. Fill Out Accident Information

3. Vehicle Information

4. Driver Information

5. Diagram of the Accident

6. Description of the Accident

7. Witness Information

8. Review and Sign

9. Submit the Form

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