Fillable Printable Form MV-104 - Report of Motor Vehicle Accident - New York

Form MV-104 - Report of Motor Vehicle Accident - New York

DRIVER OF VEHICLE 1

VEHICLE 2

BICYCLIST

PEDESTRIAN

OTHER PEDESTRIAN

Did police investigate

accident at scene?

o Yes o No

Public

Property

Damaged

Public

Property

Damaged

New York State Department of Motor Vehicles

REPORT OF MOTOR VEHICLE ACCIDENT

www.dmv.ny.gov

Accident Date

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

Day of Week Time

o AM

o PM

Number of

Vehicles

Number

Injured

Number

Killed

If “Yes”, Name of Police Agency or Precinct & Accident Number

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

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

Name–exactly as printed on registration

Address (Include Number & Street) Address (Include Number & Street)

City or Town

Date of Birth

Date of Birth Sex

Sex

Number of

People in

Vehicle

State of License

State Zip Code

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

Describe damage to vehicle 1

State of Reg. Vehicle Year & Make Vehicle Type

Ins. Code

Apt. Number

Address (Include Number & Street) Address (Include Number & Street)Apt. Number Apt. Number

Driver License ID Number

Names of All Persons Involved

How did the accident happen?

Identify Damaged Property

Other Than Vehicle(s)

VIN

Name of Insurance Company

That Issued Policy For Vehicle 1

Name and Address of

Policy Holder

Policy Period

From To

If Vehicle was Operated Under Permit

(ICC, USDOT or NYSDOT), give No.

If Self-Insured, give

Certificate No.

and State

Name and Address

of Permit Holder

Policy

Number

8. Which Veh.

Occupied

10. Safety

Equip.Used

9 . Position

in/on Vehicle

12.

Age

13.

Sex

Describe InjuriesABC

If Deceased, Enter

Date of Death

16. Injury

Date of Birth Sex

Number of

People in

Vehicle

State of License

Estimated Cost of Property Damage - Vehicle 1

o $1,001-$1,500 o $1,501-$2,500 o Over $2,500

Estimated Cost of Property Damage - Vehicle 2

o $1,001-$1,500 o $1,501-$2,500 o Over $2,500

Rear End

Sideswipe

(same direction)

Left Turn

Right Angle

1. 2.

4.3.

Sideswipe

(opposite direction)

Head On

Right Turn

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

describes the accident, or draw your own diagram below in space #9.

Number the vehicles. Your vehicle is # 1

Signature of Driver

(or Representative*)

of Vehicle 1

Print Name of Driver

(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,

check the box that describes why the driver cannot sign.

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

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

Date

Describe damage to vehicle 2

Page _______ of _______ o RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT

Month Day Year

Left Turn

Right Turn

FOLD

HERE

Use only for accidents that

happen in New York State

Month Day Year

Date of Birth Sex

Month Day Year

DRIVERREGISTRANTVEHICLE DAMAGE

INSURANCE ACCIDENT LOCATION

ALL

INVOLVED



‘

Place Where Accident Occurred in New York State:

County ______________________ of __________________________________.

Road on which accident occurred _____________________________________________________________________________________________________________

at 1) intersecting street______________________________________________________________________________________________________________________

or 2) __________ __________ ______________________________________________________________________________________

o City o Village o Town

Permanent Landmark___________________

o N o S

o E o W of

(Route Number or Street Name)

Feet

Miles (Milepost, Nearest intersecting Route Number or Street Name)

DO NOT FORGET

ACCIDENT DATE

BEFORE COMPLETING THIS FORM, READ THE INSTRUCTIONS IN SECTION A ON PAGE 2

o Injury

o Death

reset/clear

ROADWAY CHARACTER

1. Straight and Level 4. Curve and Level

2. Straight and Grade 5. Curve and Grade

3. Straight at Hillcrest 6. Curve at Hillcrest

LIGHT CONDITIONS

1. Daylight 3. Dusk 5.Dark-Road Unlighted

2. Dawn 4. Dark-Road Lighted

PEDESTRIAN/BICYCLIST/OTHER PEDESTRIAN ACTION

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

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

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

diagram which corresponds to each person’s position.

1. Driver 2-7. Passengers 8. Riding/Hanging on Outside

Veh.

First

Event

Veh.

Second

Event

Veh.

1. Other Motor Vehicle

2. Pedestrian

3. Bicyclist

4. Animal

5. Railroad Train

COLLISION WITH FIXED OBJECT

6. In-Line Skater

7. Deer

8. Other Pedestrian

10. Other Object (Not Fixed)

TYPE OF ACCIDENT

COLLISION WITH

11. Light Support/Utility Pole

12. Guide Rail - Not At End

13. Crash Cushion

14. Sign Post

15. Tree

16. Building/Wall

17. Curbing

18. Fence

19. Bridge Structure

20. Culvert/Head Wall

21. Median - Not At End

22. Snow Embankment

23. Earth Embankment/

Rock Cut/Ditch

24. Fire hydrant

25. Guide Rail - End

26. Median - End

27. Barrier

30. Other Fixed Object

NO COLLISION

31. Overturned 33. Submersion

32. Fire/Explosion 34. Ran Off Roadway Only

40. Other

11. Avoiding Object in Roadway

12. Changing Lanes

13. Passing

14. Merging

15. Backing

16. Making Right Turn on Red

17. Making Left Turn on Red

18. Police Pursuit

20. Other

1. Going Straight Ahead

2. Making Right Turn

3. Making Left Turn

4. Making U Turn

5. Starting from Parking

6. Starting in Traffic

7. Slowing or Stopping

8. Stopped in Traffic

9. Entering Parked Position

10. Parked

1. On Roadway 2. Off Roadway

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

SECTION B

USE TO COMPLETE

BOXES 1-7 and 23-30 ON PAGE 1

1. North

2. Northeast

3. East

4. Southeast

5. South

6. Southwest

7. West

8. Northwest

1. Dry

2. Wet

3. Muddy

4. Snow/Ice

5. Slush

6. Flooded

0. Other

2. Cloudy

3. Rain

4. Snow

1. Clear

5. Sleet/Hail/Freezing Rain

6. Fog/Smog/Smoke

0. Other

1. None

2. Traffic Signal

3. Stop Sign

4. Flashing Light

5. Yield Sign

6. Officer/Guard

7. No Passing Zone

8. RR Crossing Sign

9. RR Crossing Flashing Light

10. RR Crossing Gates

11. Stopped School Bus-Red

Lights Flashing

12. Construction Work Area

13. Maintenance Work Area

14. Utility Work Area

15. Police/Fire Emergency

16. School Zone

20. Other

DIRECTION OF TRAVEL

PRE-ACCIDENT VEHICLE ACTION

LOCATION OF FIRST EVENT

WEATHER

TRAFFIC CONTROL

ROADWAY SURFACE CONDITION

1. None

2. Lap Belt

3. Shoulder Restraint

4. Lap Belt Restraint

5. Child Restraint Only

6. Helmet (Motorcycle Only)

C.Helmet Only

D.Helmet/Other

E.Pads Only

F. Stoppers Only

7. Air Bag Deployed

8. Air Bag Deployed/Lap Belt

9. Air Bag Deployed/Shoulder Restraint

A. Air Bag Deployed/ Lap Belt/Restraint

B. Air Bag Deployed/Child Restraint

O. Other

SAFETY EQUIPMENT USED (Column 10)

B. Bicyclist

P. Pedestrian O. Other Pedestrian

1. Vehicle 1 2. Vehicle 2

WHICH VEHICLE OCCUPIED (Column 8) - Enter the appropriate number or letter.

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

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

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”.

‘

In-Line Skater/Bicyclist

;

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

Send

original to:

CRASH RECORDS CENTER

6 EMPIRE STATE PLAZA

PO BOX 2925

ALBANY NY 12220-0925

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.

VEHICLE INVOLVEMENT -

If you were in an accident involving:

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

information in the VEHICLE 2 section.

l 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.

l 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.

l an unoccupied vehicle, enter all available information. Be sure to enter the correct

vehicle Plate Number and Vehicle Type in the VEHICLE 2 block.

l 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

DRIVER - 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.

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.

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:

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).

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

OR SHE IS UNABLE TO SIGN BECAUSE HE/SHE IS INJURED OR DECEASED.

* 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.

Be sure your

answers are marked

INSIDE THE

BOXES ON

PAGE

PEDESTRIAN/BICYCLIST/OTHER PEDESTRIAN LOCATION

1. Pedestrian/Bicyclist/Other Pedestrian at Intersection

2. Pedestrian/Bicyclist/Other Pedestrian Not at Intersection