Report of Motor Vehicle Accident

DO NOT FORGET ACCIDENT DATE

Driver of Vehicle 1- License suspended for failure to report

RUSH

Accident Date*

Day of Week*

Time*

:

Number of Vehicles*

Number Injured*

Number Killed*

Did Police Investigate Accident at Scene?*

YES
NO

If "YES" Name of Police Agency or Precinct and Accident Number

Driver of Vehicle 1

Driver License ID Number*

State of License*

Driver Name- exactly as printed on license(Last, First,M I)*

Address (include Number and Street)*

Street Address City State ZIP Code

Date of Birth*

Sex*

Male
Female
Other

Number of People in Vehicle*

Public Property Damaged*

YES
NO

Registrant 1

Name exactly as printed on registration*

Date of Birth*

Sex*

Male
Female
Other

Address (include Number and Street)*

Street Address City State ZIP Code

Plate Number*

State of Registration*

Vehicle Year and Make*

Vehicle Type*

Insurance Code*

Vehicle 2

Was Vehicle 2 one of the following*

MOTOR VEHICLE
PEDESTRIAN
BICYCLIST
OTHER PEDESTRIAN

Driver License ID Number*

State of License*

Driver Name- exactly as printed on license(Last, First,M I)*

Address (include Number and Street)*

Street Address City State ZIP Code

Date of Birth*

Number of People in Vehicle*

Sex*

Male
Female
Other

Public Property Damaged*

YES
NO

Registrant 2

Name exactly as printed on registration*

Date of Birth*

Sex*

Male
Female
Other

Address (include Number and Street)*

Street Address City State ZIP Code

Plate Number*

State of Registration*

Vehicle Year and Make*

Vehicle Type*

Insurance Code*

Vehicle Damage

Estimated Cost of Property Damage-Vehicle 1*

$1,000-1,500
$1,501-2,500
Over 2,500

Estimated Cost of Property Damage-Vehicle 2*

$1,000-1,500
$1,501-2,500
Over 2,500

Describe Damage to Vehicle 1*

Accident Diagram: Select one of the 9 Diagrams (numbered 0-8) if it describes the accident, or draw your own diagram. Your vehicle is # 1

Draw your own diagram here

Describe Damage to Vehicle 2*

Accident Location

Place Where Accident Occured in New York State

City
Village
Town

City, Village, or Town of*

County*

Permanent Landmark*

Road on Which Accident Occurred*

At Intersecting Street

Or List Feet and Miles from Nearest Milepost, intersecting Route Number or Street Name

Direction from Nearest Milepost, intersecting Route Number or Street Name

NORTH
SOUTH
EAST
WEST

Nearest Milepost, intersecting Route Number or Street Name

How did the accident happen?*

All Involved

Names of All Persons Involved

Name

Which Vehicle Occupied?

Position in/on Vehicle

Safety Equipment Used

Age

Sex

MALE
FEMALE
OTHER

Injury

A
B
C

Describe Injuries

If Deceased Enter Date of Death

Name

Which Vehicle Occupied?

Position in/on Vehicle

Safety Equipment Used

Age

Sex

MALE
FEMALE
OTHER

Injury

A
B
C

Describe Injuries

If Deceased Enter Date of Death

Name

Which Vehicle Occupied?

Safety Equipment Used

Position in/on Vehicle

Sex

MALE
FEMALE
OTHER

Injury

A
B
C

Age

Describe Injuries

If Deceased Enter Date of Death

Name

Which Vehicle Occupied?

Safety Equipment Used

Sex

MALE
FEMALE
OTHER

Injury

A
B
C

Position in/on Vehicle

Age

Describe Injuries

If Deceased Enter Date of Death

Name

Which Vehicle Occupied?

Safety Equipment Used

Sex

MALE
FEMALE
OTHER

Injury

A
B
C

Position in/on Vehicle

Age

Describe Injuries

If Deceased Enter Date of Death

Insurance

Identify Damaged Property Other Than Vehicle(s)*

VIN*

Name of Insurance Company That Issued Policy For Vehicle(s)*

Policy Number*

Name of Policyholder*

Address of Policyholder*

Policy Period*

If Vehicle was Operated Under Permit(ICC, USDOT, or NYSDOT) give No.*

Name of Permit Holder*

Address of Permit Holder*

If Self-Insured, give Certificate No.*

State*

Date*

Print Name of Driver (or Representative) of Vehicle 1*

Signature of Driver (or Representative) of Vehicle 2*

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.*

Injury
Death

DO NOT FORGET ACCIDENT DATE

Driver of Vehicle 1

Registrant 1

Vehicle 2

Registrant 2

Vehicle Damage

Accident Location

Place Where Accident Occured in New York State

All Involved

Names of All Persons Involved

Insurance

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.