o
DRIVER OF VEHICLE 1
VEHICLE 2
o
BICYCLIST
o
PEDESTRIAN
o
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
o
o
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
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
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
Apt. Number
Address (Include Number & Street) Address (Include Number & Street)Apt. Number Apt. Number
Driver License ID 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
1
2
3
5
6
7
23
24
25
26
27
28
29
30
4
Rear End
Sideswipe
(same direction)
Left Turn
Right Angle
1. 2.
4.3.
Sideswipe
(opposite direction)
8.
Head On
7.
9.
6.
Right Turn
5.
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
0.
ç
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
Month Day Year
Date of Birth Sex
Month Day Year
Month Day Year
DRIVERREGISTRANTVEHICLE DAMAGE
INSURANCE ACCIDENT LOCATION
ALL
INVOLVED
·
¸
¹
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)
(Route Number or Street Name)
Feet
Miles (Milepost, Nearest intersecting Route Number or Street Name)
o
DO NOT FORGET
ACCIDENT DATE
BEFORE COMPLETING THIS FORM, READ THE INSTRUCTIONS IN SECTION A ON PAGE 2
o Injury
o Death
*
reset/clear
24
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
7
8
3
6
1
4
2
5
N
NE
SE
SW
NW
1
2
3
4
5
6
7
8
S
W
E
Veh.
1.
Veh.
2
Veh.
1
Veh.
2
First
Event
Veh.
1
Second
Event
6
7
5
26
27
28
29
Veh.
2
30
25
23
4
1
2
3
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
8
8
8
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”.
·
¸
¹
º
In-Line Skater/Bicyclist
>
;
9
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
1
PEDESTRIAN/BICYCLIST/OTHER PEDESTRIAN LOCATION
1. Pedestrian/Bicyclist/Other Pedestrian at Intersection
2. Pedestrian/Bicyclist/Other Pedestrian Not at Intersection
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome