Fillable Form 2: FOLD REPORT OF MOTOR VEHICLE ACCIDENT (New York State)

Fill Online, Printable, Fillable, Blank Form 2: FOLD REPORT OF MOTOR VEHICLE ACCIDENT (New York State) Form

Use Fill to complete blank online NEW YORK STATE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 2: FOLD REPORT OF MOTOR VEHICLE ACCIDENT (New York State)

On average this form takes 43 minutes to complete

The Form 2: FOLD REPORT OF MOTOR VEHICLE ACCIDENT (New York State) form is 1 page long and contains:

  • 0 signatures
  • 16 check-boxes
  • 165 other fields

Country of origin: US
File type: PDF

Free fillable forms for New York State

BROWSE NEW YORK STATE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
6
5
16. Injury 16. Injury
Reset/Clear
1
2
MV-104 (5/11) PAGE 1 of 2
HERE
FOLD
Use only for accidents that
happen in New York State
New York State Department of Motor Vehicles
REPORT OF MOTOR VEHICLE ACCIDENT
www.dmv.ny.gov
BEFORE COMPLETING THIS FORM, READ THE INSTRUCTIONS IN SECTION A ON PAGE 2
DO NOT FORGET
ACCIDENT DATE
Page _______ of _______ RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT
Accident Date
Month Day Year
Day of Week Time
AM
PM
Number of
Vehicles
Number
Injured
Number
Killed
Did police investigate
accident at scene?
Yes No
If “Yes”, Name of Police Agency or Precinct & Accident Number
DRIVER OF VEHICLE 1
VEHICLE 2 BICYCLIST
PEDESTRIAN OTHER PEDESTRIAN
DRIVER
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.)
Address (Include Number & Street)
Apt. Number
Address (Include Number & Street)
Apt. Number
City or Town State Zip Code
City or Town State Zip Code
Date of Birth
Month Day Year
Sex
Number of
People in
Vehicle
Public
Property
Damaged
Date of Birth
Month Day Year
Sex
Number of
People in
Vehicle
Public
Property
Damaged
REGISTRANT
Name–exactly as printed on registration
Date of Birth
Month Day Year
Sex
Name–exactly as printed on registration
Date of Birth
Month Day Year
Sex
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
VEHICLE DAMAGE
Estimated Cost of Property Damage - Vehicle 1
$1,001-$1,500 $1,501-$2,500 Over $2,500
Estimated Cost of Property Damage - Vehicle 2
$1,001-$1,500 $1,501-$2,500 Over $2,500
Describe damage to vehicle 1
9.
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
Left Turn
0.
Rear End
1.
Sideswipe
(same direction)
2.
Describe damage to vehicle 2
3.
Left Turn Right Angle
4.
Right Turn
5.
6.
Right Turn
Head On
7.
Sideswipe
(opposite direction)
8.
ACCIDENT LOCATION
How did the accident happen?
Place Where Accident Occurred in New York State:
County ______________________ of __________________________________.
Road on which accident occurred _____________________________________________________________________________________________________________
at 1) intersecting street______________________________________________________________________________________________________________________
or 2) __________ __________ ______________________________________________________________________________________
City Village Town
Permanent Landmark___________________
N S
E W of
(Route Number or Street Name)
(Route Number or Street Name)
Feet
Miles (Milepost, Nearest intersecting Route Number or Street Name)
ALL
INVOLVED
Names of All Persons Involved
8. Which Veh.
Occupied
9 . Position
in/on Vehicle
10. Safety
Equip.Used
12.
Age
13.
Sex
A B C
16. Injury
Describe Injuries
If Deceased, Enter
Date of Death
INSURANCE
Identify Damaged Property
Other Than Vehicle(s)
VIN
Name of Insurance Company
That Issued Policy For Vehicle 1
Policy
Number
Name and Address of
Policy Holder
Policy Period
From To
If Vehicle was Operated Under Permit
(ICC, USDOT or NYSDOT), give No.
Name and Address
of Permit Holder
If Self-Insured, give
Certificate No.
and State
Date Print Name of Driver
(or Representative*)
of Vehicle 1
Signature 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.
Injury
Death
*
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.
3
5
6
7
23
24
25
26
27
28
29
30
4
reset/clear
TYPE OF ACCIDENT TYPE OF ACCIDENT
Second
Event
COLLISION WITH FIXED OBJECT
PRE-ACCIDENT VEHICLE ACTION
DIRECTION OF TRAVEL
1
2
3
4
5
6
7
8
13. Crash Cushion
14. Sign Post
15. Tree
23. Earth Embankment/
Rock Cut/Ditch
24. Fire hydrant
11. Light Support/Utility Pole
12. Guide Rail - Not At End
21. Median - Not At End
16. Building/Wall
17. Curbing
25. Guide Rail - End
18. Fence
19. Bridge Structure
27. Barrier
20. Culvert/Head Wall
22. Snow Embankment
26. Median - End
30. Other Fixed Object
NO COLLISION
31. Overturned 33. Submersion
32. Fire/Explosion 34. Ran Off Roadway Only
40. Other
12. Changing Lanes
17. Making Left Turn on Red
18. Police Pursuit
2. Making Right Turn
7. Slowing or Stopping
8. Stopped in Traffic
11. Avoiding Object in Roadway
1. Going Straight Ahead
13. Passing
14. Merging
15. Backing
5. Starting from Parking
16. Making Right Turn on Red
9. Entering Parked Position
20. Other
3. Making Left Turn
4. Making U Turn
6. Starting in Traffic
10. Parked
2. Northeast
6. Southwest
1. North
5. South
3. East
7. West
4. Southeast
8. Northwest
MV-104 (5/11) PAGE 2 of 2
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.
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”.
* 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.
VEHICLE INVOLVEMENT -
If you were in an accident involving:
two-cars, enter your information in the VEHICLE 1 section and the other driver’s
information in the VEHICLE 2 section.
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.
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.
an unoccupied vehicle, enter all available information. Be sure to enter the correct
vehicle Plate Number and Vehicle Type in the VEHICLE 2 block.
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 -
REGISTRANT -
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 -
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 -
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:
WHICH VEHICLE OCCUPIED (Column 8) - Enter the appropriate number or letter.
1. Vehicle 1 2. Vehicle 2
B. Bicyclist
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
SAFETY EQUIPMENT USED (Column 10)
1. None
7. Air Bag Deployed
2. Lap Belt
8. Air Bag Deployed/Lap Belt
3. Shoulder Restraint
4. Lap Belt Restraint
5. Child Restraint Only
B. Air Bag Deployed/Child Restraint
6. Helmet (Motorcycle Only)
O. Other
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).
INSURANCE
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.
Send
original to:
6 EMPIRE STATE PLAZA
PO BOX 2925
ALBANY NY 12220-0925
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
7. Deer
13. Crash Cushion
14. Sign Post
15. Tree
23. Earth Embankment/
Rock Cut/Ditch
24. Fire hydrant
12. Changing Lanes
17. Making Left Turn on Red
18. Police Pursuit
2. Making Right Turn
7. Slowing or Stopping
8. Stopped in Traffic
2. Northeast
6. Southwest
2. Pedestrian
3. Bicyclist
4. Animal
5. Railroad Train
COLLISION WITH FIXED OBJECT
6. In-Line Skater
8. Other Pedestrian
10. Other Object (Not Fixed)
TYPE OF ACCIDENT
COLLISION WITH
11. Light Support/Utility Pole
12. Guide Rail - Not At End
21. Median - Not At End
16. Building/Wall
17. Curbing
25. Guide Rail - End
18. Fence
19. Bridge Structure
27. Barrier
20. Culvert/Head Wall
22. Snow Embankment
26. Median - End
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
1. Going Straight Ahead
13. Passing
14. Merging
15. Backing
5. Starting from Parking
16. Making Right Turn on Red
9. Entering Parked Position
20. Other
3. Making Left Turn
4. Making U Turn
6. Starting in Traffic
10. Parked
1. On Roadway 2. Off Roadway
SECTION B
USE TO COMPLETE
BOXES 1-7 and 23-30 ON PAGE 1
8
8
8
1. North
5. South
3. East
7. West
4. Southeast
8. Northwest
1. Dry
2. Wet
3. Muddy
4. Snow/Ice
5. Slush
6. Flooded
0. Other
2. Cloudy 5. Sleet/Hail/Freezing Rain
3. Rain
4. Snow
6. Fog/Smog/Smoke
1. Clear
0. Other
1. None
2. Traffic Signal
10. RR Crossing Gates
3. Stop Sign
4. Flashing Light
Lights Flashing
5. Yield Sign
6. Officer/Guard
7. No Passing Zone
14. Utility Work Area
8. RR Crossing Sign
9. RR Crossing Flashing Light
16. School Zone
11. Stopped School Bus-Red
12. Construction Work Area
13. Maintenance Work Area
15. Police/Fire Emergency
20. Other
DIRECTION OF TRAVEL
PRE-ACCIDENT VEHICLE ACTION
LOCATION OF FIRST EVENT
WEATHER
TRAFFIC CONTROL
ROADWAY SURFACE CONDITION
C.Helmet Only
D.Helmet/Other
E.Pads Only
F. Stoppers Only
9. Air Bag Deployed/Shoulder Restraint
A. Air Bag Deployed/ Lap Belt/Restraint
P. Pedestrian O. Other Pedestrian
In-Line Skater/Bicyclist
-
Enter damage to private property, if any, insurance policy information and VIN.
CRASH RECORDS CENTER
Enter the information for each driver EXACTLY as it appears on his/her driver license.
Enter registrant information EXACTLY as it appears on the registration of
Enter the county, locality and street(s) where the accident
List the names of all persons involved in the accident, and provide the
INSTRUCTIONS - PLEASE PRINT OR TYPE ALL INFORMATION - USE BLACK INK
* First — fold along this shaded, dotted line.*
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
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
¸
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 2: FOLD REPORT OF MOTOR VEHICLE ACCIDENT (New York State)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document