MV-104B (5/02) 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 (CDC) www.nysdmv.com 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 Time Year ! ! Number of Vehicles AM Number Injured Number Killed ! VEHICLE 2 State of License Driver License ID Number DRIVER REGISTRANT ❷ VEHICLE DAMAGE ❸ Apt. Number Address (Include Number & Street) Date of Birth Month State Sex Day Year ACCIDENT LOCATION State of License Public Property Damaged Date of Birth Month Day Address (Include Number & Street) ! Sex State Date of Birth Month Sex Day Year Public Property Damaged Date of Birth Month Day Year Apt. Number Zip Code Number of People in Vehicle Name–exactly as printed on registration ! Year 4 City or Town State Plate Number State of Reg. Vehicle Year & Make Vehicle Type Ins. Code Estimated Cost of Repairs - Vehicle 1 ! $1,001-$1,500 ! $1,501-$2,500 Describe damage to vehicle 1 State City or Town Zip Code Plate Number 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 Zip Code State of Reg. Vehicle Year & Make Vehicle Type Estimated Cost of Repairs - Vehicle 2 ! $1,001-$1,500 ! $1,501-$2,500 ! Over $2,500 Left Turn Rear End Overtaking 0. Left Turn 1. Right Angle 4. Head On 7. ! Over $2,500 INSURANCE 5 6 Describe damage to vehicle 2 5. Sideswipe 6. Ins. Code 2. Right Turn 3. Right Turn 8. 7 23 24 Place Where Accident Occurred in New York State: County ______________________ ! City ! Village ! Town of __________________________________. Permanent Landmark___________________ Road on which accident occurred _____________________________________________________________________________________________________________ (Route Number or Street Name) at or ! 1) intersecting street______________________________________________________________________________________________________________________ 2) __________ __________ Feet !N !S !E !W 25 (Route Number or Street Name) of ______________________________________________________________________________________ Miles (Milepost, Nearest intersecting Route Number or Street Name) 26 How did the accident happen? 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 If Deceased, Enter Date of Death Describe Injuries 28 VIN Policy Number Policy Period From 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. 29 To Name and Address of Permit Holder If Self-Insured, give Certificate No. 30 and State Signature of Driver (or Representative*) of Vehicle 1 Print Name 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. * 3 Sex Apt. Number Address (Include Number & Street) Damaged Property # IdentifyThan Vehicle(s) Other Date 2 Apt. Number ALL INVOLVED " ! OTHER PEDESTRIAN Address (Include Number & Street) 9. ❹ ! BICYCLIST City or Town Zip Code Number of People in Vehicle Name–exactly as printed on registration ! PEDESTRIAN Driver License ID Number Name–exactly as printed on license (Last, First, M.I.) Driver Name–exactly as printed on license (Last, First, M.I.) City or Town Did police investigate If “Yes”, Name of Police Agency or Precinct & Accident Number accident at scene? ! Yes ! No PM DRIVER OF VEHICLE 1 ❶ 1 ! 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. American LegalNet, Inc. www.FormsWorkFlow.com MV-104B (5/02) PAGE 2 of 2 SECTION B 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. 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.* * 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.nysdmv.com. ❶ 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 ❷ each vehicle involved in the accident. - Indicate if the accident exceeds the $1,000 property ❸ VEHICLE DAMAGE property caused by the accident, and describethreshold for damage. damage to any one vehicle or the vehicle ❹ ACCIDENT LOCATION - Enter the county, locality and street(s) where the accident 2. Pedestrian/Bicyclist/Other Pedestrian Not at Intersection 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 TRAFFIC CONTROL 10. RR Crossing Gates 1. None 11. Stopped School Bus-Red 2. Traffic Signal Lights Flashing 3. Stop Sign 12. Construction Work Area 4. Flashing Light 13. Maintenance Work Area 5. Yield Sign 14. Utility Work Area 6. Officer/Guard 15. Police/Fire Emergency 7. No Passing Zone 16. School Zone 8. RR Crossing Sign 9. RR Crossing Flashing Light 20. 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 - Enter damage to private property, if any, insurance policy information and VIN. 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: CERTIFIED DOCUMENT CENTER 6 EMPIRE STATE PLAZA PO BOX 2930 ALBANY NY 12220-0930 3 4 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 ROADWAY SURFACE CONDITION 5. Slush 0. Other 1. Dry 3. Muddy 6. Flooded 2. Wet 4. Snow/Ice WEATHER 1. Clear 2. Cloudy 3. Rain 4. Snow 5 6 5. Sleet/Hail/Freezing Rain 6. Fog/Smog/Smoke 0. Other ! E.Pads Only F. Stoppers Only 2 LIGHT CONDITIONS 1. Daylight 3. Dusk 5.Dark-Road Unlighted 2. Dawn 4. Dark-Road Lighted DIRECTION OF TRAVEL N NE W 1. North 5. South N 1 2 2. Northeast 6. Southwest 8 3. East 7. West E W 7 3 4. Southeast 8. Northwest 4 6 5 SW S WHICH VEHICLE OCCUPIED (Column 8) - Enter the appropriate number or letter. PRE-ACCIDENT VEHICLE ACTION 11. Avoiding Object in Roadway B. Bicyclist P. Pedestrian O. Other Pedestrian 1. Going Straight Ahead 1. Vehicle 1 2. Vehicle 2 12. Changing Lanes 2. Making Right Turn POSITION IN/ON VEHICLE (Column 9) - Enter the number from this 13. Passing 3. Making Left Turn 8 diagram which corresponds to each person’s position. 14. Merging 4. Making U Turn 1 4 15. Backing 5. Starting from Parking 7 1. Driver 2-7. Passengers 8. Riding/Hanging on Outside 8 8 2 5 16. Making Right Turn on Red 6. Starting in Traffic 6 3 17. Making Left Turn on Red 7. Slowing or Stopping 8 SAFETY EQUIPMENT USED (Column 10) 18. Police Pursuit 8. Stopped in Traffic In-Line Skater/Bicyclist 9. Entering Parked Position 7. Air Bag Deployed 1. None 20. Other 8. Air Bag Deployed/Lap Belt 2. Lap Belt 10. Parked C.Helmet Only 9. Air Bag Deployed/Shoulder Restraint 3. Shoulder Restraint LOCATION OF FIRST EVENT A. Air Bag Deployed/ Lap Belt/Restraint D.Helmet/Other 4. Lap Belt Restraint 1. On Roadway 2. Off Roadway B. Air Bag Deployed/Child Restraint 5. Child Restraint Only 6. Helmet (Motorcycle Only) O. Other 1 7 Veh. 1. 23 Veh. SE ❺ 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 - List the names of all persons involved in the accident, and provide the 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: 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 2 24 Veh. 1 25 Veh. 2 26 27 TYPE OF ACCIDENT 1. 2. 3. 4. 5. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. COLLISION WITH 6. In-Line Skater Other Motor Vehicle 7. Deer Pedestrian 8. Other Pedestrian Bicyclist 10. Other Object (Not Fixed) Animal Railroad Train First 28 Event COLLISION WITH FIXED OBJECT Light Support/Utility Pole 21. Median - Not At End 22. Snow Embankment Guide Rail - Not At End Veh. 23. Earth Embankment/ Crash Cushion 29 1 Rock Cut/Ditch Sign Post 24. Fire hydrant Tree Second 25. Guide Rail - End Event Building/Wall 26. Median - End Curbing Veh. 27. Barrier Fence 2 30 30. Other Fixed Object Bridge Structure Culvert/Head Wall 31. Overturned 32. Fire/Explosion " # NO COLLISION 33. Submersion 34. Ran Off Roadway Only 40. Other American LegalNet, Inc. www.FormsWorkFlow.com