Fillable Printable Form MV-104S - Truck and Bus Supplemental Police Accident Report - New York

Form MV-104S - Truck and Bus Supplemental Police Accident Report - New York

STATE OF LIC.

New York State Department of Motor Vehicles

TRUCK and BUS SUPPLEMENTAL

POLICE ACCIDENT REPORT

MV-104S (8/14)

Mail To: NYS Dept. of Motor Vehicles, Crash Records Center

PO Box 2084, Albany NY 12220-0084

ACCIDENT DATE

Mo. Day Year

MILITARY TIME

COUNTY

CITY/TOWN/VILLAGE

DRIVER

LICENSE ID #

DRIVER

CARRIER

DRIVER NAME - exactly as printed on license (Last, First, M.I.)

DATE OF BIRTH

LICENSE CLASS

SEX

1 Male

2 Female

CARRIER NAME

1 A 2 B 3 CDL C 4 D 5 DJ

6 E 7 M 8 MJ 9 OTHER 10 DM

STREET OR P.O. BOX

CITY STATE

ZIP CODE

CARRIER’S IDENTIFICATION NUMBERS

US DOT

MC/MX

PLATE NUMBER

TOTAL AXLES

(Includes trailers)

VEHICLE CONFIGURATION TRAFFIC WAY

1 Two-way, not divided

2 Two-way, divided, unprotected median

3 Two-way, divided, positive median barrier

4 One-way not divided

5 Not reported

1 Bus (seats 15 + people, including driver)

2 Single-unit Truck (2-axle, 6-tire)

3 Single-unit Truck (3 or more axles)

4 Truck/Trailer

5 Truck Tractor (bobtail)

6 Tractor/Semi-trailer

7 Tractor/Doubles

8 Tractor/Triples

9 Unknown Heavy Truck, cannot classify

10 Passenger Car - only record when vehicle displays

a Hazardous Material placard

11 Light truck (van, mini-van, panel, pickup, sport utility

vehicle) only record when vehicle displays an HM placard

12 Bus (seats for 9 - 15 people, including driver)

ACCESS CONTROL

1 No Access Control

2 Full Access Control

4 Partial Access Control

1 Bus (seats 15+ people, including driver)

2 Van/Enclosed Box

3 Cargo Tank

4 Flatbed

5 Dump

GVWR FOR SINGLE UNIT/GCWR FOR COMBO VEHICLES

1 Less than or equal to 10,000 lbs.

2 10,001 - 26,000 lbs. 3 More than 26,000 lbs.

VEHICLE IDENTIFICATION NUMBER

HAZARDOUS MATERIALS INVOLVEMENT

COPY FROM PLACARD:

4-digit identification number 1 or 2-digit number from

from diamond/orange pane

bottom of diamond:

Does vehicle have HazMat placard? 1 Yes 2 No

SEQUENCE OF EVENTS (FOR THIS VEHICLE)

1 Ran Off Road (noncollision)

2 Jackknife (noncollision)

3 Overturn/Rollover (noncollision)

4 Downhill Runaway (noncollision)

5 Cargo Loss or Shift (noncollision)

6 Explosion or Fire (noncollision)

7 Separation of Units (noncollision)

8 Involving Pedestrian (collision)

9 Involving Motor Vehicle in Transport (collision)

10 Involving Parked Motor Vehicle (collision)

11 Involving Train (collision)

12 Involving Pedalcycle (collision)

13 Involving Animal (collision)

14 Involving Fixed Object (collision)

18 Cross Median/Centerline (noncollision)

19 Equipment Failure (noncollision)

(brake failure, blown tires, etc.)

20 Other (noncollision)

21 Unknown (noncollision)

22 With Work Zone

Maintenance Equipment (collision)

23 With Other Movable Object (collision)

24 With Unknown Movable Object (collision)

NAME OF HAZ

MAT CLASS:

WAS HAZARDOUS CARGO RELEASED FROM VEHICLE

(other than fuel from fuel tank)?

1 Yes 2 No

OFFICER’S RANK

AND SIGNATURE

PRINT NAME

IN FULL

BADGE/ID NO. NCIC NO.

DATE OF REPORT

Mo.

Day Year

STATE OF REG.

CARGO BODY TYPE

INSTRUCTIONS You must complete this form:

u IF at least one of the vehicles involved is:

- a truck having a GVWR or GCWR > 10,000 lbs.; or

- a vehicle with a HazMat (HM) placard; or

- a bus designed to carry 9 or more persons, including the driver;

u AND at least one of the following conditions is met:

- at least one person sustained fatal injuries

- at least one person was transported for IMMEDIATE medical treatment

- at least one vehicle is disabled and was towed/transported from the scene.

Number of:

____ Trucks having a GVWR or

GCWR > 10,000 lbs.

____ Vehicles with a HazMat (HM)

placard

____ Buses designed to carry 9

or more persons

Number of Vehicles:

____ Towed/transported from scene

due to damage

Number of Persons:

____ Sustaining fatal injuries

____ Transported for IMMEDIATE

medical treatment

CARRIER TYPE

BUS TYPE

1 Intrastate Carrier

2 Interstate Carrier

3 Not in Commerce (Other Truck/Bus over 10,000 lbs.)

4 Not in Commerce - Government

1 Not a Bus

2 School

3 Transit

4 Intercity

5 Charter

6 Other

6 Concrete Mixer

7 Auto Transporter

8 Garbage/Refuse

9 Other

10 Grain, Chips, Gravel

11 Pole

12 Bus (seats 9-15 people, including driver)

13 Not Applicable/No Cargo Body Type

14 Intermodal Chassis

15 Logging

16 Vehicle Towing Another Motor Vehicle

Local Codes

Page of Pages

AMENDED REPORT