MV 104 Form Fillable Template

MV-104 5/11 PAGE 1 of 2 HERE FOLD New York State Department of Motor Vehicles Use only for accidents that happen in New York State 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 Accident Date Month Day o Page of Day of Week Time Year RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT Number of Vehicles AM Injured Killed o VEHICLE 2 State of License Driver License ID Number DRIVER REGISTRANT VEHICLE DAMAGE ACCIDENT LOCATION State Sex o OTHER PEDESTRIAN Public Property Damaged Date of Birth Address Include Number Street Apt. Reset/clear 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. 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 CRASH RECORDS CENTER 6 EMPIRE STATE PLAZA PO BOX 2925 ALBANY NY 12220-0925 5. Sleet/Hail/Freezing Rain 6. Number Zip Code People in Name exactly as printed on registration Plate Number State of Reg* Vehicle Year Make Vehicle Type Ins* Code Estimated Cost of Property Damage - Vehicle 1 o 1 001- 1 500 o 1 501- 2 500 Describe damage to vehicle 1 City or Town 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 Ins* Code o Over 2 500 Left Turn Rear End Sideswipe same direction Right Angle Head On opposite direction INSURANCE Right Turn Place Where Accident Occurred in New York State County o City o Village o Town of. Permanent Landmark Road on which accident occurred Route Number or Street Name at or o 1 intersecting street 2 Feet Miles oN oS oE oW of Milepost Nearest intersecting Route Number or Street Name How did the accident happen Names of All Persons Involved 8. Which Veh. 9. Position 10. Safety Occupied in/on Vehicle Equip*Used Age 16. Injury A B C If Deceased Enter Date of Death Describe Injuries VIN Name of Insurance Company That Issued Policy For Vehicle 1 Name and Address of Policy Holder If Vehicle was Operated Under Permit ICC USDOT or NYSDOT give No* Policy Policy Period From To of Permit Holder If Self-Insured give Certificate No* and State Signature of Driver or Representative of Vehicle 1 Print Name of Driver because of injury or death. If you are signing as the driver s representative check the box that describes why the driver cannot sign* Damaged Property IdentifyThan Vehicle s Other Date o BICYCLIST ALL INVOLVED o PEDESTRIAN Driver Name exactly as printed on license Last First M. I. Did police investigate If Yes Name of Police Agency or Precinct Accident Number accident at scene o Yes o No PM DRIVER OF VEHICLE 1 o Injury o 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.