MV-104 (5/11) PAGE 1 of 2 FOLD HERE

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 1
DO NOT FORGET
ACCIDENT DATE Page _______ of _______ RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT
Accident Date Day of Week Time Number of Number Number Did police investigate If “Yes”, Name of Police Agency or Precinct & Accident Number
Month Day Year AM Vehicles Injured Killed accident at scene?
PM Yes No
DRIVER OF VEHICLE 1 VEHICLE 2 PEDESTRIAN BICYCLIST OTHER PEDESTRIAN
2
0 Driver License ID Number State of License Driver License ID Number State of License

Driver Name–exactly as printed on license (Last, First, M.I.) Name–exactly as printed on license (Last, First, M.I.)
DRIVER

Address (Include Number & Street) Apt. Number Address (Include Number & Street) Apt. Number

City or Town State Zip Code City or Town State Zip Code

Date of Birth Sex Number of Public Date of Birth Sex Number of Public
Month Day Year People in Property Month Day Year People in Property
Vehicle Damaged Vehicle Damaged 3
@ Name–exactly as printed on registration Date of Birth
Month Day Year
Sex Name–exactly as printed on registration Date of Birth
Month Day Year
Sex
REGISTRANT

Address (Include Number & Street) Apt. Number Address (Include Number & Street) Apt. Number

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

@ Estimated Cost of Property Damage - Vehicle 1

$1,001-$1,500 $1,501-$2,500 Over $2,500
Estimated Cost of Property Damage - Vehicle 2
$1,001-$1,500 $1,501-$2,500 Over $2,500 6
VEHICLE DAMAGE

Describe damage to vehicle 1 ACCIDENT DIAGRAM: Circle one of the 9 diagrams (numbered 0-8) if it Left Turn Rear End Sideswipe Describe damage to vehicle 2
describes the accident, or draw your own diagram below in space #9. (same direction)
Number the vehicles. Your vehicle is # 1
0. 1. 2.
7
Left Turn Right Angle Right Turn

3. 4. 5. 23
Right Turn Head On Sideswipe
(opposite direction)

9. 6. 7. 8. 24
0 Place Where Accident Occurred in New York State:
County ______________________ City Village Town of __________________________________. Permanent Landmark___________________
ACCIDENT LOCATION

Road on which accident occurred _____________________________________________________________________________________________________________

(Route Number or Street Name)
at 1) intersecting street______________________________________________________________________________________________________________________ 25
(Route Number or Street Name)
N S
or 2) __________ __________ E W of ______________________________________________________________________________________
Feet Miles (Milepost, Nearest intersecting Route Number or Street Name)
26
How did the accident happen?

27
12. 13. 16. Injury
5 Names of All Persons Involved
8. Which Veh. 9. Position
Occupied
10. Safety
in/on Vehicle Equip.Used Age Sex A B C Describe Injuries
If Deceased, Enter
Date of Death
INVOLVED
ALL

28

6 Identify Damaged Property

Other Than Vehicle(s)
VIN
INSURANCE

Name of Insurance Company Policy

That Issued Policy For Vehicle 1 Number 29
Name and Address of Policy Period
Policy Holder From To
If Vehicle was Operated Under Permit Name and Address
(ICC, USDOT or NYSDOT), give No. of Permit Holder
If Self-Insured, give and State 30
Certificate No.

Date Print Name of Driver Signature of Driver

(or Representative*)
of Vehicle 1
(or Representative*)
of Vehicle 1
•
A representative may sign for the driver if the driver is unable to sign An accident report is not considered complete and filed unless it is signed,
*
because of injury or death. If you are signing as the driver’s representative,
Injury
and if not signed may result in the suspension of your driver’s license.
check the box that describes why the driver cannot sign. Death

Reset/Clear
reset/clear
MV-104 (5/11) PAGE 2 of 2
SECTION A SECTION B Be sure your
answers are marked
You must report within 10 days any accident occurring in New York State causing a fatality, USE TO COMPLETE INSIDE THE
BOXES 1-7 and 23-30 ON PAGE 1 BOXES ON
personal injury or damage over $1,000 to the property of any one person. Failure to do so
PAGE
within 10 days is a misdemeanor. Your license and/or registration may be suspended until a PEDESTRIAN/BICYCLIST/OTHER PEDESTRIAN LOCATION
1. Pedestrian/Bicyclist/Other Pedestrian at Intersection 1
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. 2. Pedestrian/Bicyclist/Other Pedestrian Not at Intersection
PEDESTRIAN/BICYCLIST/OTHER PEDESTRIAN ACTION 1
Then fill in the boxes numbered 1-7 and 23-30 in the right margin on page 1 by entering the 1. Crossing, With Signal
number of the item from Section B that best describes the circumstances of the accident. 2. Crossing, Against Signal
If a question does not apply, enter a dash (“-”). If you do not know an answer, enter an “X”. 3. Crossing, No Signal, Marked Crosswalk
INSTRUCTIONS - PLEASE PRINT OR TYPE ALL INFORMATION - USE BLACK INK 4. Crossing, No Signal or Crosswalk
5. Riding/Walking/Skating Along Highway With Traffic
* First — fold along this shaded, dotted line.* 6. Riding/Walking /Skating Along Highway Against Traffic
7. Emerging from in Front of/Behind Parked Vehicle 2
* Don’t fold internet form. Instead, place page 2 over page 1, with the arrows on
8. Going to/From Stopped School Bus
page 2 pointing to the boxes on the right edge of page 1.
9. Getting On/Off Vehicle Other Than School Bus
11. Working in Roadway
VEHICLE INVOLVEMENT - If you were in an accident involving:
12. Playing in Roadway
� two-cars, enter your information in the VEHICLE 1 section and the other driver’s
13. Other Actions in Roadway
information in the VEHICLE 2 section.
14. Not in Roadway
� a pedestrian, bicyclist or other pedestrian (a person using a non-motorized conveyance such
TRAFFIC CONTROL
as in-line skates, skateboard,sled, etc.), enter the information in the “Driver” spaces provided
1. None 10. RR Crossing Gates
for Vehicle 2, and check the PEDESTRIAN, BICYCLIST or OTHER PEDESTRIAN box.
2. Traffic Signal 11. Stopped School Bus-Red
3. Stop Sign Lights Flashing
� a vehicle other than a motor vehicle (such as a snowmobile, mini-bike, aircycle,
12. Construction Work Area
4. Flashing Light
all-terrain vehicle, trail bike, or other non-motor vehicle), enter the driver, registrant and
5. Yield Sign 13. Maintenance Work Area 3
vehicle information in the space provided for VEHICLE 2.
6. Officer/Guard 14. Utility Work Area
� an unoccupied vehicle, enter all available information. Be sure to enter the correct
7. No Passing Zone 15. Police/Fire Emergency
vehicle Plate Number and Vehicle Type in the VEHICLE 2 block.
8. RR Crossing Sign 16. School Zone
� more than two vehicles, fill out additional accident reports. On these reports, place the
9. RR Crossing Flashing Light 20. Other
information for the third vehicle in the space marked VEHICLE 1 and mark it # 3. Use the
LIGHT CONDITIONS
space marked VEHICLE 2 for the fourth vehicle, and mark it # 4 and so on. Additional forms
1. Daylight 3. Dusk 5.Dark-Road Unlighted 4
are available at any Motor Vehicles office or from the DMV website: www.dmv.ny.gov.
2. Dawn 4. Dark-Road Lighted

0 DRIVER - Enter the information for each driver EXACTLY as it appears on his/her driver license. ROADWAY CHARACTER
1. Straight and Level 4. Curve and Level 5
@ each
REGISTRANT - Enter registrant information EXACTLY as it appears on the registration of
vehicle involved in the accident.
2. Straight and Grade
3. Straight at Hillcrest
5. Curve and Grade
6. Curve at Hillcrest
ROADWAY SURFACE CONDITION
¸ VEHICLE DAMAGE - Indicate if the accident exceeds the $1,000 threshold for property damage

to any one vehicle or property caused by the accident, and describe the vehicle damage.

1. Dry
2. Wet
3. Muddy
4. Snow/Ice
5. Slush
6. Flooded
0. Other 6

0 ACCIDENT LOCATION - Enter the county, locality and street(s) where the accident WEATHER
1. Clear
2. Cloudy
3. Rain
5. Sleet/Hail/Freezing Rain
6. Fog/Smog/Smoke 7
occurred. Check the box if there is an intersecting street. If available, identify a permanent 4. Snow 0. Other
landmark nearby, such as a business, school, shopping mall, parking lot, water tower, DIRECTION OF TRAVEL
railroad, mountain or cell tower. N Veh.
0 W NE 23
ALL INVOLVED - List the names of all persons involved in the accident, and provide the N 1. North 5. South 1.
date of death if anyone was killed in, or as a result of, the accident. If more than four 8 1 2. Northeast 6. Southwest
2
people are involved, complete another report. In the ALL INVOLVED section of that W 7 3 E 3. East 7. West
6 4 4. Southeast 8. Northwest Veh.
report, provide the required information for everyone else involved in the accident. Enter 5
the following codes in the appropriate columns: SW 24
SE
2
S
WHICH VEHICLE OCCUPIED (Column 8) - Enter the appropriate number or letter. PRE-ACCIDENT VEHICLE ACTION
1. Vehicle 1 2. Vehicle 2 B. Bicyclist P. Pedestrian O. Other Pedestrian 1. Going Straight Ahead 11. Avoiding Object in Roadway
11.
2. Making Right Turn 12. Changing Lanes Veh.
POSITION IN/ON VEHICLE (Column 9) - Enter the number from this
3. Making Left Turn 13. Passing 1 25
8
diagram which corresponds to each person’s position.
4 1
4. Making U Turn 14. Merging
5. Starting from Parking 15. Backing
1. Driver 2-7. Passengers 8. Riding/Hanging on Outside 8 7 5 2 8
6. Starting in Traffic 16. Making Right Turn on Red
6 3
SAFETY EQUIPMENT USED (Column 10) 8 7. Slowing or Stopping 17. Making Left Turn on Red Veh.
8. Stopped in Traffic 18. Police Pursuit 2 26
1. None 7. Air Bag Deployed In-Line Skater/Bicyclist 9. Entering Parked Position 20. Other
2. Lap Belt 8. Air Bag Deployed/Lap Belt 10. Parked
3. Shoulder Restraint 9. Air Bag Deployed/Shoulder Restraint C.Helmet Only LOCATION OF FIRST EVENT
4. Lap Belt Restraint A. Air Bag Deployed/ Lap Belt/Restraint D.Helmet/Other 1. On Roadway 2. Off Roadway
27
5. Child Restraint Only B. Air Bag Deployed/Child Restraint E.Pads Only
6. Helmet (Motorcycle Only) O. Other F. Stoppers Only TYPE OF ACCIDENT
COLLISION WITH
INJURY (Columns 16A-C) - Check all column(s) that apply and DESCRIBE INJURIES:
1. Other Motor Vehicle 6. In-Line Skater First
2. Pedestrian 7. Deer 28
A - Severe lacerations, broken or distorted limbs, skull fracture, crushed chest, internal
3. Bicyclist 8. Other Pedestrian Event
injuries, unconscious when taken from the accident scene, unable to leave accident
4. Animal 10. Other Object (Not Fixed)
scene without assistance.
5. Railroad Train
B - Lump on head, abrasions, minor lacerations.
COLLISION WITH FIXED OBJECT
C - Momentary unconsciousness, limping, nausea, hysteria, complaint of pain (no visible
11.
11. Light Support/Utility
Light Support/Utility Pole 21. Median
Pole 21. Median -- Not
Not At At End
End
injury), whiplash (complaint of neck and head pain). 12.
12. Guide
Guide Rail
Rail -- Not
Not At
At End
End 22. Snow
22. Snow Embankment
Embankment
13.
13. Crash Cushion
Crash Cushion 23. Earth
23. Earth Embankment/
Embankment/ Veh.
� INSURANCE - Enter damage to private property, if any, insurance policy information and VIN. 14.
14.
15.
15.
Sign Post
Sign
Tree
Tree
Post Rock Cut/Ditch
Rock
24. Fire
24.
Cut/Ditch
Fire hydrant
hydrant Second
1
29

Attach additional reports to page one. Each page of the report must be numbered in the upper 16.
16. Building/Wall
Building/Wall 25. Guide
25. Guide Rail
Rail -- End
End Event
left corner. Mark additional sheets #2, #3, etc. Date and sign on the bottom line of each 17.
17. Curbing
Curbing 26. Median
26. Median -- End
End
18.
18. Fence
Fence 27. Barrier
27. Barrier Veh.
attached report. THE REPORT MUST BE SIGNED BY THE DRIVER OF VEHICLE 1, UNLESS HE 19.
19. Bridge Structure
Bridge Structure 30. Other
30. Other Fixed
Fixed Object
Object 2 30
OR SHE IS UNABLE TO SIGN BECAUSE HE/SHE IS INJURED OR DECEASED. 20.
20. Culvert/Head Wall
Culvert/Head Wall
Send original to:
CRASH RECORDS CENTER NO COLLISION
NO COLLISION
6 EMPIRE STATE PLAZA
31. Overturned
31. Overturned 33. Submersion
33. Submersion
PO BOX 2925
32. Fire/Explosion
32. Fire/Explosion 34. Ran
34. Ran Off
Off Roadway
Roadway Only
Only
40. Other
40. Other
ALBANY NY 12220-0925