Vermont Form Report – Fill Out and Use This PDF

REPORT OF A MOTOR VEHICLE CRASH

DEPARTMENT OF MOTOR VEHICLES

FOR OFFICE USE ONLY

Agency of Transportation

A crash with more than 2 vehicles involved must fill

DMV Crash Number

120 State Street

out as many forms as needed to include all vehicles

Montpelier, Vermont 05603-0001

involved in the crash.

(voice) 802.828.2050

YOUR VEHICLE ~ NO. 1

NUMBER OF OCCUPANTS

OTHER VEHICLE ~ NO. 2

NUMBER OF OCCUPANTS

OR PEDESTRIAN OR BICYCLIST

OPERATOR NAME: LAST

FIRST

MIDDLE

OPERATOR NAME: LAST

FIRST

MIDDLE

STREET OR BOX NO.

STREET OR BOX NO.

CITY OR TOWN

STATE

CITY OR TOWN

STATE

ZIP CODE

DATE OF BIRTH

GENDER

ZIP CODE

DATE OF BIRTH

GENDER

OPERATOR’S LICENSE NO.

CLASS

STATE

OPERATOR’S LICENSE NO.

CLASS

STATE

IDENTIFICATION NUMBER

PLATE NUMBER

PLATE STATE

IDENTIFICATION NUMBER

PLATE NUMBER

PLATE STATE

VEHICLE YEAR

VEHICLE MAKE

VEHICLE MODEL

VEHICLE TYPE

VEHICLE YEAR

VEHICLE MAKE

VEHICLE MODEL

VEHICLE TYPE

TRAILER YEAR

TRAILER MAKE

TRAILER MODEL

TRAILER PLATE #

TRAILER YEAR

TRAILER MAKE

TRAILER MODEL

TRAILER PLATE #

COMMERCIAL

YES

NO

HAZARDOUS

YES

NO

COMMERCIAL

YES

NO

HAZARDOUS

YES

NO

VEHICLE

MATERIAL

VEHICLE

MATERIAL

ACTUAL COST

IF THE CRASH INVOLVED A PEDESTRIAN OR A BICYCLIST, COMPLETE

ACTUAL COST

OF VEHICLE #1

THE FOLLOWING INFORMATION

OF VEHICLE #2

REPAIRS

WHAT WAS PEDESTRIAN OR BICYCLIST DOING

REPAIRS

PROPERTY

WALKING WITH TRAFFIC

PLAYING IN ROAD

UNKNOWN

PROPERTY

WALKING AGAINST TRAFFIC

GETTING ON/OFF VEHICLE

DAMAGE OTHER

DAMAGE OTHER

THAN VEHICLE

NOT IN ROADWAY

PUSHING VEHICLE

THAN VEHICLE

APPROXIMATE

CROSSING INTERSECTION

WORKING ON VEHICLE

APPROXIMATE

COST OF

CROSSING NOT AT AN

RIDING/PUSHING BIKE

COST OF

PROPERTY

INTERSECTION

PROPERTY

REPAIRS

REPAIRS

OTHER:

PROPERTY OWNER’S NAME

PROPERTY OWNER’S NAME

AND ADDRESS:

AND ADDRESS:

DESCRIBE INJURY:

OCCUPANT DATA

THE INFORMATION BELOW IS REQUIRED FOR YOURSELF AND ALL OCCUPANTS IN ALL VEHICLES

(ATTACH ADDITIONAL SHEETS IF THERE IS NOT ENOUGH ROOM BELOW)

THIS INFORMATION IS REQUIRED

OCCUPANT’S NAME AND ADDRESS

NATURE AND EXTENT OF

NAME OF HOSPITAL

WAS

WAS

POSITION

AGE

SEATBELT

OCCUPANT

(USE THE FIRST LINE FOR YOURSELF EVEN IF NOT

INJURY

INJURED TAKEN TO

VEH

WITHIN

OF

GENDER

OR

THROWN

INJURED

(STATE “NONE” IF NOT INJURED)

NO

VEHICLE

OCC.

HARNESS

FROM

USED

VEHICLE

1

YOURSELF

DRIVER

damage insurance in effect on the date of the above crash? You must answer Yes or No.

Yes

No

Name of your (Operator 1) Insurance Company (NOT AGENT):

Insurance Company Mailing

Address:

Policy Number:

Policy Period From:

to

Name of Policy Holder:

Address:

Name of Operator at the time of the Crash:

Date of Crash:

Is this motor vehicle covered by a Certificate of Self-Insurance?

Yes

No

If yes, certificate number:

DO NOT DETACH FORM SR-21A

VERMONT DEPARTMENT OF MOTOR VEHICLES MONTPELIER VERMONT

DMV CRASH NUMBER

VERMONT

Name of insurance company with whom you are insured for liability or damage to others (For Operator #1):

Insurance Company mailing address:

Policy Number:

Policy Period From:

to

Date of Crash:

At or near (Town/City):

Make of your vehicle:

Year:

Type:

VIN:

Operator:

Address:

Name of Policy Holder:

Signature of Operator:

NAME OF INSURANCE COMPANY :

BY :

DATE :

AUTHORIZED REPRESENTATIVE