Fillable Missouri DOR - Form 1140 Motor Vehicle Accident Report

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Missouri DOR - Form 1140 Motor Vehicle Accident Report

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MO 860-0427 (6-2006) DOR-1140 (6-2006)
MISSOURI DEPARTMENT OF REVENUE
DRIVER LICENSE BUREAU
MOTOR VEHICLE ACCIDENT REPORT
FORM
1140
(REV. 6-2006)
GENERAL INFORMATION
(The following information is based on Chapter 303 RSMo.)
Q: When should I file this accident report?
A: File this report if all of the following are true:
The accident happened in Missouri.
The accident happened within the last 12 months.
Someone involved in the accident did not have insurance.
Q: Can I submit the police report instead of completing this accident report?
A: No. The law requires you to report the accident using the attached form.
Q: What happens after this report is filed?
A: An uninsured person’s driver license and/or plates can be taken away for one or both of the following reasons:
• He/she does not show us proof of insurance for the accident.
• He/she is found to be at fault for the accident and does not send secur
ity compliance (see below) to us.
Q: What is security?
A: Security is the amount of money that we find the uninsured person(s) is responsible for based on his/her percentage
of fault for the accident and the amount of damages on file. The most common forms of secur
ity compliance are:
• Installment Agreement: A notarized payment plan agreed to by you and the uninsured person(s).
• Release: A sworn statement from you releasing the uninsured person(s) from responsibility for the accident.
• Cash Deposit: A deposit of cash sent to us from the uninsured person(s) for the full amount of security.
We must return the deposit to the uninsured person(s) after one year from the accident date unless the parties
agree to a settlement or a lawsuit is filed against the person(s) for whom the deposit was made.
The deposit can only be applied toward a judgment against the person(s) for whom the deposit was made.
We will send you instructions on how to obtain the deposit, if one is made.
• One-Year Suspension: The uninsured person(s) can choose to remain suspended for one year instead of submit-
ting security compliance. The suspension can be extended if a lawsuit is filed in court within one year of the acci-
dent date and a copy of the petition is sent to us.
Q: Will the state file the lawsuit?
A: No. You must file the lawsuit in court if you wish to do so.
Q: Will you let me know when the uninsured person’s driver license and/or plates will be suspended?
A: Yes, if you contact us. Please allow up to 90 days for us to process your accident report and determine a percentage
of fault for the accident.
Q: How can I contact you?
A: You may contact us at Driver License Bureau, P.O. Box 200, Jefferson City, Missouri 65105-0200,
dlbmail@dor.mo.gov or (573) 751-7195.
Q: Is the accident report form available on the Internet?
A: Yes. The Motor Vehicle Accident Report Form is now available in fillable PDF format. Visit our web site at
www.dor.mo.gov/mvdl/ for more information.
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MO 860-0427 (6-2006) DOR-1140 (6-2006)
MISSOURI DEPARTMENT OF REVENUE
DRIVER LICENSE BUREAU
MOTOR VEHICLE ACCIDENT REPORT
FORM
1140
(REV. 6-2006)
INSTRUCTIONS FOR COMPLETING THIS FORM.
PART 1: Fill in all blanks with the information requested.
PART 2: Fill in your vehicle driver and owner information. If the vehicle was parked, write “parked” in the vehicle driver
box and fill in the owner information. If you were not a vehicle driver or owner, mark the correct box under “Your
Involvement” and fill in the information in the spaces provided.
Fill in your liability insurance information and mark the correct box. (This is only required if you are the vehicle
driver and/or owner.)
PART 3: Sign your name and mark the correct box.
PART 4: Fill in the driver, owner, and vehicle information for all other involved parties.
PART 5: Draw a diagram of the accident using the symbols and instructions on the form.
Explain how the accident happened, in your own words.
Attach a denial letter from the uninsured person’s insurance company, if you have one. The letter should state the reason
why coverage was denied for the accident. It must be on the company’s stationery and signed by the person who reviewed
the claim.
PROPERTY DAMAGE AND/OR BODILY INJURY DOCUMENTS
1. In order to determine a percentage of fault and require security for your loss, both of the following statements must
apply.
A. There was more than $500 in damage to one or more person’s property, or there was bodily injury or death.
B. It has been less than nine months since the accident happened.
Reason: A notice must be sent to the uninsured person within one year of the accident date. We need 90 days
to process the accident report and determine a percentage of fault for the accident.
2. If statements 1.A and 1.B do apply, attach any of the following documents that pertain to this accident.
• An estimate of repair cost for the vehicle or other property. (It must be readable, itemized, and contain the accident
date or estimate date. It must also contain the name and address of the repair shop or insurance company);
• A doctor’s report and/or medical bills. (The type of injury must be explained in detail and the service date must be
included. It must also contain the name and address of the healthcare provider); and/or
• A copy of a death certificate or police report showing there was a death.
3. If statements 1.A. and/or 1.B. do not apply, the uninsured person’s driver license and/or plates can be taken away for
not having insurance at the time of the accident. The accident report must be mailed to us within one year of the
accident date.
MAIL THE COMPLETED ACCIDENT REPORT FORM AND ANY ATTACHMENTS TO THE DRIVER LICENSE BUREAU,
P.O. BOX 200, JEFFERSON CITY, MISSOURI 65105-0200, OR FAX TO (573) 526-7365.
MO 860-0427 (6-2006) DOR-1140 (6-2006)
MISSOURI DEPARTMENT OF REVENUE
DRIVER LICENSE BUREAU
MOTOR VEHICLE ACCIDENT REPORT
FORM
1140
(REV. 6-2006)
DOR USE ONLY
NAIC NUMBER ORI NUMBER CASE NUMBER
PART 1 — ACCIDENT INFORMATION
➞➞
ONLY REPORT ACCIDENTS OCCURRING IN MISSOURI
PART 2 — YOUR INFORMATION
STOP
ACCIDENT DATE TIME COUNTY STATE
ACCIDENT LOCATION - STREET NAME OR HIGHWAY NUMBER NUMBER OF VEHICLES INVOLVED WAS A POLICE REPORT MADE? IF YES, WHAT POLICE AGENCY
YES NO
A.M.
P.M.
DRIVER’S NAME SEX OWNER’S NAME DATE OF BIRTH SEX
STREET ADDRESS STREET ADDRESS DRIVER LICENSE NUMBER
CITY, STATE ZIP CODE CITY, STATE ZIP CODE
DATE OF BIRTH DRIVER LICENSE NUMBER STATE VEHICLE MAKE/YEAR MODEL LICENSE PLATE NUMBER STATE
VEHICLE DRIVER
INVOLVEMENT (IF OTHER THAN VEHICLE DRIVER/OWNER)
VEHICLE OWNER
PASSENGER
PEDESTRIAN
PROPERTY OWNER (OTHER THAN VEHICLE)
TYPE OF PROPERTY ______________________
OTHER __________________________________
NAME DATE OF BIRTH SEX
STREET ADDRESS DRIVER LICENSE NUMBER
CITY, STATE ZIP CODE
YOUR LIABILITY INSURANCE INFORMATION
WAS YOUR VEHICLE COVERED BY LIABILITY INSURANCE AT THE TIME OF THE ACCIDENT?
YES NO
➞➞
YOU MUST MARK A BOX!
IMPORTANT! IF YOU MARK YES, YOU MUST PROVIDE YOUR INSURANCE COMPANY NAME AND
POLICY NUMBER BELOW.
FAILURE TO PROVIDE THIS INFORMATION MAY RESULT IN SUSPENSION ACTION.
STOP
PART 3 — SIGNATURE
➞➞
YOU MUST SIGN THE REPORT OR IT WILL BE RETURNED TO YOU
STOP
INSURANCE COMPANY NAME (NOT AGENCY OR BROKERAGE) INSURANCE POLICY/CLAIM NUMBER
I STATE THAT THE INFORMATION ON BOTH SIDES OF THIS REPORT IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
SIGNATURE
I AM:
DRIVER OWNER PROPERTY OWNER ATTORNEY PASSENGER PEDESTRIAN
INSURANCE COMPANY REPRESENTATIVE CORPORATE OFFICER
COMPLETE REVERSE SIDE
➞➞
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MO 860-0427 (6-2006) DOR-1140 (6-2006)
PART 5 — DIAGRAM DESCRIPTION OF ACCIDENT
OTHER VEHICLE — OWNER INFORMATION
OTHER VEHICLE — OWNER INFORMATION
OTHER VEHICLE — DRIVER INFORMATION
OTHER VEHICLE — DRIVER INFORMATION
OWNER’S NAME DATE OF BIRTH SEX
STREET ADDRESS DRIVER LICENSE NUMBER
CITY, STATE ZIP CODE
VEHICLE MAKE/YEAR MODEL LICENSE PLATE NUMBER STATE
PART 4 — OTHER INVOLVED PARTIES (USE ADDITIONAL FORMS IF NECESSARY)
INSTRUCTIONS
SYMBOLS
DRAW PICTURE OF ROADWAY AT PLACE OF
ACCIDENT. NUMBER EACH VEHICLE AND SHOW
DIRECTION OF TRAVEL BY ARROW.
EXAMPLE
➞
➞
12
1. VEHICLE 4. RAILROAD
2. MOTORCYCLE 5. UTILITY POLE
3. PEDESTRIAN
NORTH
➜
DESCRIBE WHAT HAPPENED (REFER TO VEHICLES BY NUMBER, AND BY NAME OF DRIVER(S))
MAIL TO: MISSOURI DEPARTMENT OF REVENUE, DRIVER LICENSE BUREAU, P.O. BOX 200, JEFFERSON CITY, MISSOURI 65105-0200,
OR FAX TO: (573) 526-7365. PHONE: (573) 751-7195. E-MAIL: dlbmail@dor.mo.gov
OTHER VEHICLE — OWNER INFORMATIONOTHER VEHICLE — DRIVER INFORMATION
DRIVER’S NAME SEX
STREET ADDRESS
CITY, STATE ZIP CODE
DATE OF BIRTH DRIVER LICENSE NUMBER STATE
OWNER’S NAME DATE OF BIRTH SEX
STREET ADDRESS DRIVER LICENSE NUMBER
CITY, STATE ZIP CODE
VEHICLE MAKE/YEAR MODEL LICENSE PLATE NUMBER STATE
DRIVER’S NAME SEX
STREET ADDRESS
CITY, STATE ZIP CODE
DATE OF BIRTH DRIVER LICENSE NUMBER STATE
OWNER’S NAME DATE OF BIRTH SEX
STREET ADDRESS DRIVER LICENSE NUMBER
CITY, STATE ZIP CODE
VEHICLE MAKE/YEAR MODEL LICENSE PLATE NUMBER STATE
DRIVER’S NAME SEX
STREET ADDRESS
CITY, STATE ZIP CODE
DATE OF BIRTH DRIVER LICENSE NUMBER STATE
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Missouri DOR - Form 1140 Motor Vehicle Accident Report

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Completed 26 May 2020

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