MV-104 (5/22) PAGE 1 of 2
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RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT
Month
03 Day
03 Year
2023
03 Day
03 Year
2023
day of Week
second
second
Time
AM
PM
Number of Vehicles
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Number Injured
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Number Killed
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Did police investigate accident at scene?
Yes
No
If “Yes”, Name of Police Agency or Precinct & Accident Number
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DRIVER OF VEHICLE 1
VEHICLE 2
PEDESTRIAN
BICYCLIST
OTHER PEDESTRIAN
1
Driver License ID Number
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State of License
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Driver License ID Number
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State of License
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Driver Name–exactly as printed on license (Last, First, M.I.)
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Name–exactly as printed on license (Last, First, M.I.)
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Address (Include Number & Street)
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Apt. Number
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Address (Include Number & Street)
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Apt. Number
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City or Town
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State
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Zip Code
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City or Town
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State
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Zip Code
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Date of Birth
Month
09 Day
08 Year
2023
09 Day
08 Year
2023
Sex
Female
Female
Number of People in Vehicle
98988889
Date of Birth
Month
08 Day
08 Year
2023
08 Day
08 Year
2023
Sex
male
male
Number of People in Vehicle
98987789
2
Name–exactly as printed on registration
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Date of Birth
Month 10
Day 11
Year 2023
Sex
Male
Male
Name–exactly as printed on registration
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Date of Birth
Month 11
Day 11
Year 2023
Sex
Female
Female
Address (Include Number & Street)
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Apt. Number
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Address (Include Number & Street)
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Apt. Number
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City or Town
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State
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Zip Code
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City or Town
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State
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Zip Code
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Plate Number
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State of Reg
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Vehicle Year & Make
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Vehicle Type
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Ins. Code
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Plate Number
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State of Reg
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Vehicle Year & Make
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Vehicle Type
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Ins. Code
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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
Describe damage to vehicle 1
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ACCIDENT DIAGRAM: Circle one of the 9 diagrams (numbered 0-8) if it describes the
accident, or draw your own diagram below in space #9. Number the vehicles. Your vehicle is # 1
9.
9.
Left Turn
Rear End
Sideswipe
(same direction)
(same direction)
Left Turn
Right Angle
Right Turn
Right Turn
Head On
Sideswipe
(opposite direction)
(opposite direction)
Describe damage to vehicle 2
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4
Place Where Accident Occurred in New York State:
County sas
City
Village
Town
of text here
Permanent Landmark text here
Road on which accident occurred
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at
1) intersecting street
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or 2)
1
5
N
E
S
W
of
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Names of All Persons Involved
8. Which Veh. Occupied
9 . Position in/on Vehicle
10. Safety Equip.Used
12. Age
13. Sex
16. Injury
A
B
C
Describe Injuries
If Deceased, Enter Date of Death
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54
male
34
4
43
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54
male
34
4
43
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54
male
34
4
43
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54
male
34
4
43
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Identify Damaged Property Other Than Vehicle(s)
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VIN
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Name of Insurance Company That Issued Policy For Vehicle 1
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Policy
Number sample text here
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Name and Address of Policy Holde
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-
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Policy Period
From 3434 To 432434
From 3434 To 432434
If Vehicle was Operated Under Permit (ICC, USDOT or NYSDOT), give No.
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Name and Address of Permit Holder
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-
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if Self-Insured, give Certificate No
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and State
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Date
08/20/1990
08/20/1990
Print Name of Driver (or Representative*) of Vehicle 1
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Signature of Driver (or Representative*) of Vehicle 1
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* 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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