Fillable Form New York DMV Accident Report

What is the New York DMV Accident Report Form?

The New York DMV Accident Report Form, also known as MV-104 Form, is a Department of Motor Vehicles (DMV) form in New York which must be completed if one was involved in a vehicle accident.

Within 10 days of the occurrence of the said accident, this form must be filled out in accordance withSection 605 of the NY State Vehicle and Traffic Law.

This form must be filled out if in the accident there was a person who was injured or killed or if
there is damage to the property of one individual (including yourself) in excess of more than $1,000.

Failure to file your own accident report within 10 days from the date of accident or DMV may suspend your driver’s license until your report is received.

How to fill out the New York DMV Accident Report?

The form is straightforward and easy to fill out for it contains only six (6) sections.

Section 1- Driver

Driver of Vehicle 1
Driver License ID Number
Enter driver license ID number of the driver.

State of License
Enter the state of the driver license.

Driver Name
Provide the name of the driver involved in the accident.

Address
Provide the address of the driver involved in the accident.

Apartment Number
Enter the apartment number where the driver resides.

City or Town
Enter the city or town where the driver’s address is located.

State
Enter the state where the driver’s address is located.

Zip Code
Enter the zip code of the driver’s address.

Date of Birth
Enter the driver’s date of birth.

Sex
Enter the orientation of the driver.

Number of People in Vehicle
Enter the number of people in the vehicle when the accident happened.

Public Property Damaged
Select if public property was damaged.

For the other portion of Section 1, identify the other party accordingly (Driver, Pedestrian,Bicyclist, or Other Pedestrian).

Driver License ID Number
Enter driver license ID number of the driver.

State of License
Enter the state of the driver license.

Driver Name
Provide the name of the driver involved in the accident.

Address
Provide the address of the driver involved in the accident.

Apartment Number
Enter the apartment number where the driver resides.

City or Town
Enter the city or town where the driver’s address is located.

State
Enter the state where the driver’s address is located.

Zip Code
Enter the zip code of the driver’s address.

Date of Birth
Enter the driver’s date of birth.

Sex
Enter the orientation of the driver.

Number of People in Vehicle
Enter the number of people in the vehicle when the accident happened.

Public Property Damaged
Select if public property was damaged.

Section 2- Registrant

Name
Enter the name of the registrant exactly as printed on registration.

Date of Birth
Enter the registrant’s date of birth.

Sex
Enter the orientation of the registrant.

Address
Provide the address of the registrant.

Apartment Number
Enter the apartment number where the registrant resides.

City or Town
Enter the city or town where the registrant’s address is located.

State
Enter the state where the registrant’s address is located.

Zip Code
Enter the zip code of the registrant’s address.

Plate number
Provide the plate number of the vehicle.

State of Reg.
Enter the state of the vehicle’s registration.

Vehicle Year & Make
Enter the year and make of the vehicle.

Vehicle Type
Enter the type of vehicle involved.

Ins. Code
Enter the insurance code of the vehicle.

Section 3- Vehicle Damage

Estimated Cost of Property Damage- Vehicle 1 & 2
Select the estimated cost of damage to Vehicle 1 and 2 respectively ($1,001-$1,500; $1,501-$2,500; or Over $2,500). Then, describe the damage on the space provided and use the accident diagram.

Section 4- Accident Location

Place Where Accident Occured in New York State:
Enter the required information including the County, Permanent Landmark, Nearest milepost, intersecting route or street name, and how the accident happened on the space provided.

Section 5- All Involved
In this section, enter the names of all the persons involved, which vehicle each person is in, their respective position in/on vehicle, the safety equipment used, age, sex, injury and date of death (if deceased).

Section 6- Insurance

Identify Damaged Property Other Than Vehicle(s)
Specify here if there are other properties damaged other than the vehicles listed above.

VIN
Enter the Vehicle Identification Number (VIN).

Name of Insurance Company That Issued Policy For Vehicle 1
Enter the name of the insurance company that issued policy for Vehicle 1.

Policy Number
Enter the policy number that Vehicle 1 was under in.

Name and Address of Policy Holder
Enter the name and address of the policy holder.

Policy Period
Enter the start and end date of the policy on the space provided.

If Vehicle was Operated Under Permit, give No.
If the vehicle was operated under ICC, USDOT, or NYSDOT, enter the permit number.

Name and Address of Permit Holder
Enter the name and address of who holds the permit.

If Self-insured, give Certificate No.
Enter the certificate number on the space provided, if self-insured.

Date
Enter the date the form was completed and signed.

Print name of driver of Vehicle 1
Enter the name of the driver of Vehicle 1. If you are a representative filling out the form on behalf of the driver, enter your name and select the reason why you are representing the driver (Injury or Death).

Signature of driver of Vehicle 1
Provide your signature.

Submission

Upon completing the form, you may mail it to:

CRASH RECORDS CENTER
6 EMPIRE STATE PLAZA
PO BOX 2925
ALBANY NY 12220-0925

Tips

• If the accident caused property damage only, you still have to file the New York DMV Accident Report form and exchange information about your driver license, insurance, and registration with the involved drivers.
• If a person is injured or killed, you are required to notify the police immediately and it is expected that you will also file the MV-104 as soon as possible by the NY State Vehicle and Traffic Law.
• You must locate the owner or contact the police if other property (not owned by either party) is damaged or if a domestic animal is injured, you must locate the owner and/or contact the police.
• If personal injury or death was caused and was left behind by a driver, he will face criminal charges.
• Do not hesitate to file the New York DMV Accident Report. Filing this does not mean that you were at fault. The accident will appear on the records of all the involved drivers.