STATE OF NEW HAMPSHIRE
Department of Safety
Division of Motor Vehicles
MOTOR VEHICLE ACCIDENT REPORT
N.H.RSA 264:25 – REPORTING REQUIRMENTS
In the State of New Hampshire, any Motor Vehicle Accident causing death, personal injury, or combined vehicle/property damage in excess of $1,000 must be reported in writing to the
Division of Motor Vehicles within 15 days. Failure to report in the case of death or personal injury is a felony. Failure to report following a property damage only accident is a misdemeanor.
INSTRUCTIONS—PLEASE PRINT OR TYPE ALL INFORMATION—USE BLACK OR DARK BLUE INK
SECTION A
ACCIDENT OCCURRED 1. AT THE INTERSECTION WITH
ROUTE # and/or EXIT # OR STREET NAME
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
N
ON
2. FEET W E OF
ROUTE # OR STREET NAME S ROUTE # and/or EXIT # OR STREET NAME
3
4
1
5
2 6
7
S
ECTION C
AGE SEX
8 9 10 11 12 NAME(S) OF OCCUPANTS IN YOUR VEHICLE / WITNESSES ADDRESS / PHONE NO. 13 14 15
DSMV 400 (Rev. 04/12) SEE REVERSE SIDE
DATE OF ACCIDENT DAY OF WEEK TIME AM
PM
CITY/TOWN
NUMBER OF
VEHICLES
DID
POLICE INVESTIGATE
YES
ACCIDENT AT SCENE?
NO
POLICE DEPARTMENT
1 2 3
4 5 6
7
9
10
1. The date and location of the accident is very important and
you must describe it as accurately and completely as possible in
the space provided. When describing the location of your
accident, indicate the direction and distance from the crash site
to the nearest intersecting road or, for interstate highways, to the
nearest mileage marker or exit number.
2. In Section C, for each occupant of your vehicle, or for a
pedestrian or bicyclist, enter the requested information on a
single line. Utilize a further report form if more than six persons
involved. For a witness, enter a “W” in the “WHICH VEHICLE
OCCUPIED” column; for a Pedestrian, enter a “P” in the box; for
a Bicyclist, enter a “B” . For a new born child (less than one year)
enter “NB” for age. Enter “M” for Male and “F” for female.
3. You must enter Injury information on all occupants,
utilizing the following designations:
K – Any injury that results in death.
A Severe lacerations, broke or distorted limbs, skull frac-
ture, crushed chest, internal injuries, unconscious
when taken from the accident scene, unable to leave the
accident scene without assistance.
B – Lump on head, abrasions, minor lacerations.
C – Momentary unconsciousness. Limping, nausea, hysteria,
complaint of pain (no visible injury).
U – Unknown.
N – Not injured.
4. Give your own and your vehicles owner’s CURRENT
name and address when completing the YOUR VEHICLE part of
the form. Report all other driver’s and vehicle’s information
exactly as it appears on their licenses and registrations. If you
were involved in an accident with a Pedestrian or Bicyclist, check
the appropriate box under OTHER VEHICLE and enter the
Pedestrian or Bicyclist information in the OTHER VEHICLE –
DRIVER section. If the other vehicle was unoccupied, be very
sure to enter the correct vehicle plate number and vehicle make
in the appropriate boxes. If you were involved in an accident in
which there were more than two vehicles, additional report(s)
must be filled out.
5. If you are driving a Commercial Motor Vehicle (Truck over
26,000 GVWR, Bus with more than fifteen seats, or vehicle
placarded for Hazardous Materials), please indicate it in the
appropriate box.
6. It is mandatory to provide complete insurance information
in the section provided, or to indicate that your vehicle and/or
license does not have insurance coverage. Your report must be
signed and dated, else the report cannot be accepted.
7. If you have difficulty completing this form, your insurance
agent may be able to assist you, otherwise contact the Accident
Section of the Division of Motor Vehicles at (603) 227-4040
(Speech/Hearing Impaired HELP TTY/TDD Relay 225-4033).
8. Submit your completed and signed reports to:
Department of Safety
Accident Section
23 Hazen Drive
Concord, NH 03305
Use the
one that
applies
SECTION B
Enter the number of the item in the corresponding box provided
which best describes the circumstances of the accident.
COLLISION WITH:
1. Other Motor Vehicle
2. Motor Vehicle Crossing Median
3. Parked Motor Vehicle
4. Railroad Train
5. Bicyclist
6. Pedestrian
7. Animal
8. Thrown or Falling Object
9. Other Object
17.Motor Vehicle in Transport
18. Pedal Cycle/Moped
19. Snowmobile/OHRV
10. Fixed Object
NON-COLLISION
11. Overturn
12. Spill (2 Wheel Vehicle)
13. Fire
14. Submersion
15. Jackknife
16. Explosion
98. Other*
1. At Intersection
2. Intersection Related
3. Along the Road
4. Along Road at Driveway Access
5. Off Roadway on Shoulder/Median
6. Off Roadway Beyond Shoulder
1. Traffic Signal
2. Sign Post
3. Guard Rail
4. Crash Cushion
5. Light Pole
6. Telephone/Electric Pole
7. Tree
8. Building Wall
9. Bridge/Pier
10. Median
11. Barrier/Fence
12. Culvert/Headwall
13. Embankment/Ditch/Curb
14. Fire Hydrant/Parking Meter
15. RR Crossing Device
16. Overpass
17. Rock/Sideslope
98. Other*
7. Ramp/Rotary
8. Toll Plaza/Booth
9. In a Driveway
10.In a Parking Lot
98.Other*
1. None
2. Traffic Signals
3. Stop Sign
4. Yield Sign
5. Lane Control
6. Visible Road Markings
7. Officer/Flagman
8. RR Crossing-Flasher-Gate
9. No Passing Zone
98.Other*
1. Interstate
2. Other Divided Highway
3. Not Physically Divided
(2-way Traffic)
4. Undivided Road (1-Way Traffic)
5. Driveway or Access Way
98.Other*
1. Dry
2. Wet
3. Sno
w/Sl
ush
4. Ice
5. Muddy
6. Debris
7.
Sand/D
ust/Oil
98. Other*
99. Unknown
1. Clear
2. Cloudy
3. Rain
4. Snow
5. Sleet
6. Fog
7. Blowing Material
8. Severe Cross Winds
9. Rain and Fog
10. Sleet and Fog
11. No Adverse Conditions
99. Unknown
TYPE OF INJURY
K, A, B, C, U, N
(See Instructions
Above)
LOCATION OF MOST
SEVERE INJURY
1. Head
2. Neck
3. Chest
4. Arm(s)
5. Trunk/Torso
6. Leg(s)
7. Multiple
8. None
99.Unknown
WHICH VEHICLE
OCCUPIED?
VEHICLE
8
1. Driver
2-7. Passengers
8. Ride/Hang
on Vehicle
9. Driver
( 2/3/ W
heeled Vehicle)
10. Passengers
( 2/3/
Wheeled Vehicle)
11. Sidecar/Sled/
Hang on Vehicle
99. Unknown
THROWN FROM VEHICLE? Yes / No
SAFETY EQUIPMENT UTILIZED Code
Seat Belts used S
Child Restraint used C
Air Bag Deployed A
Air Bag & Seat Belt B
Helmet Worn (Motorcycles) H
No equipment used --
If you enter 10 in box 1, enter number below for OBJECT STRUCT in box 2.
Otherwise leave box 2 blank.
TYPE OF ACCIDENT
ACCIDENT LOCATION
TRAFFIC CONTROLS
ROAD DESIGN
ROAD SURFACE CONDITIONS
WEATHER
8
8
OCCUPANT’S/INJURED’S POSITION
IN OR ON:
11
M.V. Use Only
MOTORCYCLE/BIKE/
SNOWMOBILE
*Without DESCRIPTION OF ACCIDENT, ESTIMATE OF REPAIR, or OPERATOR’S SIGNATURE, report will NOT be accepted.
SECTION D
BICYCLIST
YOUR VEHICLE OTHER VEHICLE
PEDESTRIAN
DRIVER LICENSE NO.
STATE
CLASSIFICATION
DRIVER LICENSE NO.
STATE
CLASSIFICATION
DRIVER’S NAME LAST, FIRST, MIDDLE
DRIVER’S NAME LAST, FIRST, MIDDLE
D.O.B.
SEX
D.O.B.
SEX
CURRENT ADDRESS, NUMBER AND STREET
PHONE NO.
CURRENT ADDRESS, NUMBER AND STREET
PHONE NO.
CITY/TOWN
STATE
ZIP CODE
CITY/TOWN
STATE
ZIP CODE
PLATE NO.
STATE
TRAILER PLATE NO.
STATE
PLATE NO.
STATE
TRAILER PLATE NO.
STATE
SAME
AS
DRIVER
OWNER NAME LAST, FIRST, MIDDLE
SAME
AS
DRIVER
OWNER NAME LAST, FIRST, MIDDLE
CURRENT ADDRESS, NUMBER AND STREET
PHONE NO.
CURRENT ADDRESS, NUMBER AND STREET
PHONE NO.
CITY/TOWN
STATE
ZIP CODE
CITY/TOWN
STATE
ZIP CODE
MAKE
YEAR
COMMERCIAL
VEHICLE
ACCIDENT
MAKE
YEAR
COMMERCIAL
VEHICLE
ACCIDENT
V.I.N.
V.I.N.
VEHICLE
TOWED
BY
TO
VEHICLE
TOWED
BY
TO
DESCRIBE DAMAGE TO VEHICLE
DESCRIBE DAMAGE TO VEHICLE
*ESTIMATED COST TO REPAIR
*ESTIMATED COST TO REPAIR
SECTION E
YOUR INSURANCE CO.
ESTIMATED PROPERTY DAMAGE (OTHER THAN VEHICLE)
AGENT
ADDRESS
POLICY NUMBER
EFFECTIVE DATE
IDENTIFY DAMAGED PROPERTY OTHER THAN VEHICLE(S)
SECTION F
Rear
1
Passing
2
Lt. Turn
3
Intersection
4
Rt. Turn
5
Rt. Turn
6
Head On
7
Sideswipe
8
* DESCRIBE THE ACCIDENT
* OPERATOR’S SIGNATURE DATE OF REPORT
( DAY / MONTH / YEAR)
16
17
18
19
20
21
ACCIDENT DIAGRAM
Check one of the diagrams if it adequately describes the accident, OR draw your own diagram
on a separate sheet and attach. Number the vehicles, with your vehicle being No. 1.
1. Automobile
2. Pick-Up/Light Truck
3. Panel/Van
8. Motorcycle
9. Moped
10. Motor Home
11. Passenger Light Van
12. Utility Vehicle (4x4)
13. Other/Unknown
Light Truck
97. Motor Carrier
98. Other* *
VEHICLE TYPE
VEHICLE DIRECTION
1. North
2. East
3. South
4. West
99. Unknown
V
EHICLE:
(Box 20 and/or 21)
1. Following Roadway
2. Right Turn on Red
3. Making Right Turn
4. Making Left Turn
5. Making U-Turn
6. Starting From Parked
7. Starting in Traffic
8. Slowing or Stopping
9. Stopping in Traffic
10. Entering Park Position
11. Parked Properly
12. Parked and Rolled
13. Changing Lanes/Merging
14. Overtaking/Passing
15. Passing on Right
16. Backing
17. Parked Improperly
18. Avoid Something in Road
19. Wrong Way on a 1-Way
97. OTHER Action in Road
(Box 21 only)
41. Crossing with Signal
42. Crossing against Signal
43. Crossing at Crosswalk No Signal
44. Crossing No Signal/Crosswalk
45. Walk/Ride with Traffic
46. Walk/Ride against Traffic
47. Emerge from Front/Rear of
Parked Vehicle
48. Get On/Off School Bus
49. Get On/Off Vehicle
50. Pushing/Working on Vehicle
51. Playing/Jogging
52. Standing/Walking
98. OTHER Pedestrian/Bicyclist
Action
PRE-ACCIDENT ACTION
YOUR
Vehicle
YOUR
Vehicle
YOUR
Vehicle
Other
Vehicle
Other
Vehicle
Other
Vehicle
or
Ped/Bike
2
1
2
1
1
2
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