MV-104 (5/11) PAGE 1 of 2 Use only for accidents that happen in New York State FOLD HERE www.dmv.ny.gov New York State Department of Motor Vehicles REPORT OF MOTOR VEHICLE ACCIDENT BEFORE COMPLETING THIS FORM, READ THE INSTRUCTIONS IN SECTION A ON PAGE 2 DO NOT FORGET ACCIDENT DATE Accident Date Month Day Page _______ of _______ Day of Week Year Time o Number of Vehicles 1 RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT Number Injured Number Killed Did police investigate If "Yes", Name of Police Agency or Precinct & Accident Number accident at scene? o Yes o No o o AM PM DRIVER OF VEHICLE 1 ¶ DRIVER o VEHICLE 2 State of License o PEDESTRIAN o BICYCLIST o OTHER PEDESTRIAN State of License Driver License ID Number Driver Name­exactly as printed on license (Last, First, M.I.) Address (Include Number & Street) Driver License ID Number Name­exactly as printed on license (Last, First, M.I.) 2 Apt. Number Address (Include Number & Street) Apt. Number City or Town Date of Birth Month Sex Day Year State Number of People in Vehicle Zip Code Public Property Damaged Year Apt. Number City or Town Date of Birth Month Sex Day Year State Number of People in Vehicle Zip Code Public Property Damaged Year Apt. Number REGISTRANT · o o 3 Name­exactly as printed on registration Date of Birth Month Day Sex Name­exactly as printed on registration Date of Birth Month Day Sex Address (Include Number & Street) Address (Include Number & Street) 4 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 5 6 7 ¸ VEHICLE DAMAGE Estimated Cost of Property Damage - Vehicle 1 o $1,001-$1,500 o $1,501-$2,500 Describe damage to vehicle 1 o Over $2,500 Estimated Cost of Property Damage - Vehicle 2 o $1,001-$1,500 o $1,501-$2,500 Left Turn Rear End Sideswipe (same direction) 2. Right Turn o Over $2,500 Describe damage to vehicle 2 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. Left Turn 1. Right Angle 3. Right Turn 4. Head On 5. Sideswipe (opposite direction) 8. 23 ¹ ACCIDENT LOCATION 9. Place Where Accident Occurred in New York State: County ______________________ 6. 7. 24 o City o Village o Town of __________________________________. Permanent Landmark___________________ Road on which accident occurred _____________________________________________________________________________________________________________ at or o 1) intersecting street______________________________________________________________________________________________________________________ 2) __________ __________ Feet Miles (Route Number or Street Name) (Route Number or Street Name) 25 oN oS oE oW of ______________________________________________________________________________________ (Milepost, Nearest intersecting Route Number or Street Name) How did the accident happen? 26 27 Names of All Persons Involved 8. Which Veh. 9. Position 10. Safety Occupied in/on Vehicle Equip.Used 12. Age 13. Sex 16. Injury A B C Describe Injuries If Deceased, Enter Date of Death ALL INVOLVED 28 INSURANCE Damaged Property ` IdentifyThan Vehicle(s) Other 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. If Self-Insured, give Certificate No. Print Name of Driver (or Representative*) of Vehicle 1 Signature of Driver (or Representative*) of Vehicle 1 Name and Address of Permit Holder VIN Policy Number Policy Period From 29 To and State 30 Date ç 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. * 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. American LegalNet, Inc. www.FormsWorkFlow.com MV-104 (5/11) PAGE 2 of 2 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". INSTRUCTIONS - PLEASE PRINT OR TYPE ALL INFORMATION - USE BLACK INK * First -- fold along this shaded, dotted line.* SECTION A Be sure your answers are marked INSIDE THE USE TO COMPLETE BOXES ON BOXES 1-7 and 23-30 ON PAGE 1 PAGE PEDESTRIAN/BICYCLIST/OTHER PEDESTRIAN LOCATION 1 1. Pedestrian/Bicyclist/Other Pedestrian at Intersection SECTION B * 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: 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 l l l ¶ 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. - Indicate if the accident exceeds the $1,000 property ¸ VEHICLE DAMAGE property caused by the accident, and describethreshold for damage. damage to any one vehicle or the vehicle 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 unoccu