New York State Department of Motor Vehicles …

1 ! vehicle 1(YOUR vehicle ) vehicle 2!BICYCLIST!PEDESTRIAN!Did police investigate accident at scene?!Yes !NoPublicPropertyDamagedPublicPropertyDa magedNew York State Department of Motor VehiclesREPORT OF Motor vehicle ACCIDENTDMVUSEA ccident DateMV-104 (6/00) PAGE 1 Day of WeekTime! AM!PM!!No. of VehiclesNo. InjuredNo. KilledIf Yes , Name of Police AgencyDriver Name exactly as printed on licenseName exactly as printed on licenseName exactly as printed on registrationName exactly as printed on registrationDMV USEA ddress (Include Number & Street)Address (Include Number & Street)City or TownDate of BirthDate of BirthDate of BirthSexUnlicensed!No. of of CodeCity or TownStateZip CodeCity or TownStateZip CodeCity or TownStateZip CodePlate NumberState of Year & MakeVehicle TypeIns. CodePlate NumberDescribe damage to vehicle 1 State of Year & MakeVehicle TypeIns.

2 CodeApt. (Include Number & Street)Address (Include Number & Street)Apt. No.!City !Village!Town !Miles !N !E!Feet !S !W of!At Intersection WithDRIVERVEHICLER eference MarkerNew York County of OccurrenceRoute No. or Street NameNearest Intersecting Route/StreetLeftSceneVehicle 2 License ID 1 License ID USEALL PERSONS INVOLVED(see instruction 6 on page 2):Name and AddressHow did the accident happen?Identify Damaged Property Other Than vehicle (s)Name of Insurance Company That Issued PolicyName and Address of Policy HolderPolicy PeriodFrom ToIf vehicle was Operated Under Permit(ICC, USDOT or NYSDOT), give Form SR-23 (Fleet Coverage)on File with DMV? !Yes !NoIf Self-Insured, give Certificate StateName and Addressof Permit HolderPolicy Number8. InVeh. Positionin InjuriesKABCDate of Death16. Check all column(s) that instruction 6 on page // /Date of BirthSexUnlicensed!

3 No. of of /Estimated Cost of Repairs - vehicle 1!$1000 or less!$1001-$1200!$1201-$1400!$1401-$1600 !$1601-$1800!Over $1800 Estimated Cost of Repairs - vehicle 2!$1000 or less!$1001-$1200!$1201-$1400!$1401-$1600 !$1601-$1800!Over$18001245678910113 Rear EndOvertakingLeft TurnRight DIAGRAM:Circle one of the 9 diagrams (numbered 0-8) if it describes the accident. Or draw your owndiagram below in space # the Vehicles . Your vehicle is No. 1 0. Signature of Driver (or Representative) of vehicle 1 Print Name of Driver (or Representative) of vehicle 1A representative may sign for the driver if the driver is unable to signbecause of injury or death. If you are signing as the driver srepresentative, check the box that describes why the driver cannot sign.!Injury !DeathDateDescribe damage to vehicle 2DO NOT FORGETACCIDENT DATE Page _____ of _____ !

4 RUSH- DRIVER OF vehicle 1 - LICENSE SUSPENDED FOR FAILURE TO REPORTM onth Day YearLeft TurnRight TurnBEFORE COMPLETING THIS FORM, READ THE INSTRUCTIONS IN SECTION A ON PAGE 2 SECTION AYou must report within 10 days any accident occurring in New York Statecausing death, personal injury or damage over $1000 to the property of anyone person. Failure to do so within 10 days is a misdemeanor. Your licenseand/or registration may be suspended until a report is filed. Check the RUSH box at the top of page 1 if your license is suspended for failure to report thisaccident on must fill in all information requested on the PRINT OR TYPE ALL INFORMATION - USE BLACK INK*First - fold along this line.*Then fill in the 11 boxes in the right margin (on page 1 of form) byentering the number of the item which best describes thecircumstances of the accident.

5 If a question does not apply, enter adash (-). If an answer is unknown, enter an x .*Don t fold internetform. Instead, place page 2 over page 1 with thearrows on page 2 pointing to the boxes on the right edge of page If you were involved in an accident with a pedestrian, enter the pedestrianinformation in the Driver spaces provided for vehicle 2, and check the PEDESTRIAN you were involved in an accident with a vehicle other than a Motor vehicle (such as a snowmobile, mini-bike, aircycle, all-terrain vehicle , trail bike, orother non- Motor vehicle ), enter the driver, owner and vehicle information in thespace provided for vehicle a vehicle is unoccupied, enter all available information. Be sure to enter thecorrect vehicle plate number and vehicle type in the vehicle Enter driver information EXACTLY as it appears on each driver owner information EXACTLY as it appears on the registration of eachvehicle involved in the If more than two Vehicles were involved in this accident, fill out additionalaccident reports.

6 On these reports, place the information for the third vehicle inthe space marked YOUR vehicle and mark it No. 3. Use the space markedVEHICLE 2 for the fourth vehicle , and mark it No. 4 and so on. Additionalforms are available at any Motor Vehicles office or from the DMV website: Enter the street or route name, the distance and direction from the nearest intersection, and the name or route number of that intersecting street. 5. If the accident occurred on a State highway, you will find a small green signcalled a reference marker somewhere near the crash site. In the ReferenceMarker section, write the number EXACTLYas it appears on the For ALL PERSONS INVOLVED in the accident, list their names and addresses and fill in Boxes 8, 10, 11, 12, 13. For any person killed or injured, describe injuries and check appropriate injury code in Box 16.

7 If anyonewas killed in, or as a result of, the accident, provide the date of a P in Box 8 for pedestrians, and a B for FOR SAFETY EQUIPMENT USED (Box 10):1. None6. Helmet2. Lap Belt7. Air Bag Deployed3. Harness8. Air Bag Deployed/Lap Belt4. Lap Belt Harness9. Air Bag Deployed/Harness5. Child Restraint OnlyA. Air Bag Deployed/Lap Belt/HarnessB. Air Bag Deployed/Child RestraintPOSITION IN/ON vehicle (Box 11):1. Driver 2-7. Passengers8. Riding/Hanging on OutsideIn Box 11, enter the number from this diagram which corresponds to each person s CODES (Box 16):K - Any injury that results in - Severe lacerations, broken or distorted limbs, skull fracture, crushedchest, internal injuries, unconscious when taken from the accidentscene, unable to leave accident scene without - Lump on head, abrasions, minor - Momentary unconsciousness, limping, nausea, hysteria, complaint ofpain (no visible injury).

8 If more than four people are involved, another report is needed. In the ALLPERSONS INVOLVED section of that report, record the required informationfor everyone else involved in the Attach additional reports to page one. Each page of the report must be numbered in the upper right corner. Mark additional sheets #2, #3, etc. Date andsign on the bottom line of each attached REPORT MUSTBE SIGNED BY THE DRIVER OF vehicle 1, UNLESS HE OR SHE IS INJURED OR originalto:ACCIDENT RECORDS BUREAUPO BOX 29256 EMPIRE State PLAZAALBANY NY 12220-092578361425 PEDESTRIAN/BICYCLIST LOCATION1. Pedestrian/Bicyclist at Not at IntersectionPEDESTRIAN/BICYCLIST ACTION1. Crossing, With Signal2. Crossing, Against Signal3. Crossing, No Signal, Marked Crosswalk4. Crossing, No Signal or Crosswalk5. Riding/Walking Along Highway With Traffic6. Riding/Walking Along Highway Against Traffic7.

9 Emerging from in Front of/Behind Parked Vehicle8. Going to/From Stopped School Bus9. Getting On/Off vehicle Other Than School Bus10. Pushing/Working On Car11. Working in Roadway12. Playing in Roadway13. Other Actions in Roadway14. Not in Roadway (Indicate)TRAFFIC CONTROL1. None9. RR Crossing Flashing Light2. Traffic Signal10. RR Crossing Gates3. Stop Sign11. Stopped School Bus-Red4. Flashing LightLights Flashing5. Yield Sign12. Construction Work Area6. Officer/Guard13. Maintenance Work Area7. No Passing Zone14. Utility Work Area8. RR Crossing Sign20. OtherROADWAY1. Straight and Level4. Curve and Level2. Straight and Grade5. Curve and Grade3. Straight at Hillcrest6. Curve at HillcrestROADWAY SURFACE1. Dry4. Snow/Ice2. Wet5. Slush3. Muddy0. OtherWEATHER1. Clear4. Snow2. Cloudy5. Sleet/Hail/Freezing Rain3. Rain6.

10 Fog/Smog/Smoke0. OtherDIRECTION OF TRAVEL1. North2. Northeast3. East4. Southeast5. South6. Southwest7. West8. NorthwestPRE-ACCIDENT vehicle ACTIONN neseswnw12345678 SWE1234567 YourVehicle8 Vehicle29 YourVehicle10 Vehicle2111. Other Motor Vehicle2. Pedestrian3. BicyclistCOLLISION WITH FIXED OBJECT4. Animal5. Railroad Train6. In-Line Skater10. Other Object (Not Fixed)TYPE OF ACCIDENTCOLLISION WITH11. Light Support/Utility Pole12. Guide Rail - Not At End13. Crash Cushion14. Sign Post15. Tree16. Building/Wall17. Curbing18. Fence19. Bridge Structure20. Culvert/Head Wall21. Median - Not At End22. Snow Embankment23. Earth Embankment/Rock Cut/Ditch24. Fire hydrant25. Guide Rail - End26. Median - End27. Barrier30. Other Fixed ObjectNO COLLISION31. Overturned33. Submersion32. Fire/Explosion34. Ran Off Roadway Only40. Other10. Parked11.