MV 104 NY Report Accident Form – Fill Out and Use This PDF

The MV-104 NY Report Accident form is an official document used for reporting motor vehicle accidents that occur within New York State to the Department of Motor Vehicles (DMV). It's mandatory for incidents involving fatalities, personal injuries, or property damage exceeding $1,000 to any one person's property. Completing and submitting this form within ten days of an accident is crucial in order to avoid legal repercussions, including the possibility of misdemeanor charges or the suspension of driving privileges. To ensure compliance with New York State law and to protect one's driving record, it's important to accurately fill out and promptly submit the MV-104 form.

For detailed guidance on completing the form and to ensure all necessary information is correctly provided, click the button below.

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Mv 104 Ny Report Accident Form PDF Details

In New York State, residents involved in vehicle accidents causing fatalities, injuries, or property damage exceeding $1,000 must complete and submit the MV-104 form to the New York State Department of Motor Vehicles (DMV). This comprehensive document requests detailed information on the involved parties, the location of the accident, and the circumstances surrounding the event. Besides personal and vehicle information for all parties involved, the form requires an accident diagram, descriptions of vehicle damage, and an assessment of injuries. The accident location is to be specified with both a description and a diagram to offer clear understanding of how the incident occurred. The necessity to report within 10 days of the accident is underlined by the potential legal ramifications of failing to do so, including the classification of such failure as a misdemeanor and the possibility of license and/or registration suspension until the report is filed. Intended to facilitate an objective and comprehensive account of the incident for the DMV records, the MV-104 form plays a critical role in post-accident procedures, emphasizing the importance of accuracy and promptness in its completion and submission.

Question	Answer
Form Name	MV 104 NY Report Accident Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	150
Avg. time to fill out	12 min
Other names	DMV 104, report an accident, NY accident report, NY report accident

Form Preview Example

MV-104 (5/11) 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.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

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?

Yes

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.)

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

@ 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

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
			0.	1.	2.
VEHICLE			Left Turn	Right Angle	Right Turn
VEHICLE			3.	4.	5.
			3.	4.	5.
			Right Turn	Head On	Sideswipe
					(opposite direction)
		9.	6.	7.	8.

0 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)

1)intersectingstreet______________________________________________________________________________________________________________________

(Route Number or Street Name)

2) __________ __________

______________________________________________________________________________________

ACCIDENT

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

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

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*

ofinjuryordeath.Ifyouaresigningasthedriver’srepresentative,

Injury

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

checktheboxthatdescribeswhythedrivercannotsign.

Death

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

How to Edit MV 104 NY Report Accident Form Online for Free

The MV-104 NY Report Accident Form must be completed accurately and submitted promptly to ensure compliance with state laws and facilitate the processing of insurance claims.

1. Determine If You Need to Report

Verify whether the accident meets the criteria for reporting to the DMV, which includes any incident with personal injury, fatality, or significant property damage. This step is crucial as failing to report such accidents can lead to legal penalties.

2. Collect Necessary Information

Gather all relevant information from the accident scene, including details of all vehicles and drivers involved, insurance information, and a precise description of the accident location and conditions.

mv 104 fillable writing process outlined (step 1)

3. Document Accident Details

Fill in the accident date, time, and location on the form. Provide detailed descriptions, including the street names, intersections, and any landmarks to pinpoint the exact location of the accident.

4. Fill in Driver and Vehicle Information

Enter complete driver information for each vehicle involved in the accident, including driver's license numbers, addresses, and vehicle descriptions. Make sure to include license plate numbers and insurance details.

5. Describe the Accident

Provide a detailed account of how the accident occurred in the section provided. Include all drivers' actions leading up to the accident and any contributing environmental factors.

mv 104 fillable completion process outlined (portion 2)

6. Diagram the Accident

Utilize the diagram section to represent the accident's dynamics visually. This should include the positions of the vehicles at the time of the accident and their movements during the incident.

7. Report Damage and Injuries

List all damages to the vehicles and other property, and describe the nature and extent of injuries sustained by any individuals involved. Be precise in estimating the cost of damage and detailing the injuries.

8. Verify Insurance Information

Double-check that all insurance information provided is accurate and complete. This includes the insurance company name, policy number, and the period the policy covers.

mv 104 fillable writing process shown (part 4)

9. Review and Sign the Form

Carefully review the entire form to ensure all information is correct and complete. Sign and date the form to verify the accuracy of the information provided. When you use FormsPal, you can easily fill out forms without the need to worry about personal data incidents or records getting distributed. Our protected platform makes sure that your personal information is maintained safely.

MV 104 NY Report Accident Form – Fill Out and Use This PDF

Mv 104 Ny Report Accident Form PDF Details

Form Preview Example

How to Edit MV 104 NY Report Accident Form Online for Free

1. Determine If You Need to Report

2. Collect Necessary Information

3. Document Accident Details

4. Fill in Driver and Vehicle Information

5. Describe the Accident

6. Diagram the Accident

7. Report Damage and Injuries

8. Verify Insurance Information

9. Review and Sign the Form

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