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Contact
en español
Home
About
Our Team
Our Locations
News
Reviews
Service Areas
Staten Island, NY
Brooklyn, NY
Manhattan, NY
New Jersey
Personal Injury
Slip and Falls, and Trip and Falls
ACCIDENT F.A.Q’s
Auto, Bus, & Train Accidents
Motorcycle Accident
Tractor-Trailer Accidents
Hit and Run Help
Uninsured Motorist Claims
Dog Bites
Construction Accidents
Sexual Harassment
Medical Malpractice
Burn Victims
Nursing Home Neglect and Abuse
Schools, Parks, and Playgrounds
Casino Slips and Falls
Worker’s Compensation
Social Security Disability
Social Security Disability
What Is SSD?
SSD F.A.Q’s
SSD vs. SSI?
Does Marriage Or Divorce Affect SSD?
Survivor Benefits
How Do You Determine Your “Onset Date”?
What Does It Take To Be Insured?
What Is “Functional Impairment”?
What Is Residual Functional Capacity?
Why Are Most Initial Applications Denied?
Coronavirus and SSD
Criminal Defense
Settlements
Long-Term Disability
Mass Torts
3M Military Earplugs Lawsuit
Belviq Cancer Lawsuits
Elmiron Eye Disease Lawsuits
JUUL Nicotine Addiction Lawsuits
Zantac Cancer Lawsuits
Contact
en español
Report of Motor Vehicle Accident
2019-10-16T12:47:59-04:00
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
*
:
Hours
Minutes
AM
PM
AM/PM
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
0
1
2
3
4
5
6
7
8
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
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.
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