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Crash Report BMV 3303 - Ohio
| Crash Report Form. This is a Ohio form and can be used in Financial Responsibility Related Bureau Of Motor Vehicles Statewide . |
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OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES CRASH REPORT YOU MUST COMPLETE ALL SECTIONS OF THIS REPORT AND SIGN PLEASE TYPE OR PRINT IN INK (BLUE OR BLACK) BMV USE ONLY The driver of a vehicle which is involved in a motor vehicle accident may file this report with the BMV within six months after the accident if both the following apply: (1) there was any personal injury or there was property damage in excess of $400.00, and (2) the driver or owner of the other vehicle did not have insurance or other financial responsibility coverage at the time of the accident. PLEASE NOTE: Medical expenses or property damages MUST be documented and submitted with this report. Incomplete reports or forms received more than six months after the date of the accident WILL NOT be processed or returned. Please answer all questions to the best of your knowledge. DATE OF ACCIDENT TIME OF DAY ACCIDENT LOCATION (COUNTY) CITY A.M. P.M. WAS A POLICE REPORT TAKEN? YES NO IF SO, PLEASE PROVIDE A COPY OF THE POLICE REPORT NUMBER OF VEHICLES INVOLVED WHERE ACCIDENT OCCURRED (STREET NAME) 1 YOUR VEHICLE INFORMATION DRIVER NAME ADDRESS CITY DATE OF BIRTH DRIVER LICENSE # TYPE OF VEHICLE LICENSE PLATE # OWNER NAME OWNER ADDRESS CITY DATE OF BIRTH PHONE # STATE ZIP CODE YEAR STATE ZIP CODE 2 OTHER VEHICLE INVOLVED YOU MUST PROVIDE IDENTIFIERS YES NO WAS THIS VEHICLE INSURED? DRIVER NAME ADDRESS CITY DATE OF BIRTH DRIVER LICENSE # TYPE OF VEHICLE LICENSE PLATE # OWNER NAME OWNER ADDRESS CITY DATE OF BIRTH PHONE # POLICY # NAME OF POLICY HOLDER STATE YEAR STATE ZIP CODE SOCIAL SECURITY # ISSUING STATE MAKE WAS THIS VEHICLE PARKED LEGALLY? YES NO SOCIAL SECURITY # ISSUING STATE MAKE ISSUING DATE WAS THIS VEHICLE PARKED LEGALLY? YES NO ISSUING DATE ZIP CODE SOCIAL SECURITY # DRIVER LICENSE # AND STATE SOCIAL SECURITY # DRIVER LICENSE # AND STATE EFFECTIVE DATES FROM TO MUST COVER ACCIDENT DATE A INSURANCE INFORMATION INSURANCE CLAIM OFFICE HANDLING THE CLAIM NAME ADDRESS CITY PHONE # INSURANCE COMPANY NAME AGENT SIGNATURE DATE STATE ZIP CODE YOUR INSURANCE AGENT MUST FILL OUT AND SIGN THIS SECTION WAS THERE A LIABILITY INSURANCE POLICY IN EFFECT COVERING YOUR INSURED IF A DAMAGE CLAIM ARISES FROM THIS ACCIDENT? YES NO AGENCY STAMP X SELF INSURED OR UNDER FLEET COVERAGE, ICC OR PUCO Do you operate under fleet coverage (SR23) on file with Registrar of Motor Vehicles? YES NO Has Registrar issued a Certificate of Self-Ins.? YES NO PERMIT NO. Was your vehicle operating under authority of PUCO or ICC? YES NO PERMIT NO. COMPLETE REVERSE SIDE BMV 3303 12/12 [760-0998] Page 1 of 2 PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com 3 OTHER VEHICLE INVOLVED YOU MUST PROVIDE IDENTIFIERS YES NO WAS THIS VEHICLE INSURED? DRIVER NAME ADDRESS CITY DATE OF BIRTH DRIVER LICENSE # TYPE OF VEHICLE LICENSE PLATE # OWNER NAME OWNER ADDRESS CITY DATE OF BIRTH PHONE # STATE YEAR MAKE STATE 4 OTHER VEHICLE INVOLVED YOU MUST PROVIDE IDENTIFIERS YES NO WAS THIS VEHICLE INSURED? DRIVER NAME ADDRESS ZIP CODE SOCIAL SECURITY # ISSUING STATE WAS THIS VEHICLE PARKED LEGALLY? YES NO CITY DATE OF BIRTH DRIVER LICENSE # TYPE OF VEHICLE LICENSE PLATE # OWNER NAME OWNER ADDRESS STATE ZIP CODE SOCIAL SECURITY # ISSUING STATE YEAR MAKE ISSUING DATE ISSUING DATE WAS THIS VEHICLE PARKED LEGALLY? YES NO ZIP CODE CITY DATE OF BIRTH PHONE # STATE ZIP CODE SOCIAL SECURITY # DRIVER LICENSE # AND STATE SOCIAL SECURITY # DRIVER LICENSE # AND STATE IF ADDITIONAL VEHICLES INVOLVED - USE SECOND SHEET B DAMAGE SECTION NAME OF REPAIR FACILITY BUSINESS ADDRESS Please document the amount of damage your property or vehicle incurred or any injury suffered by you or a passenger in your vehicle. To document your vehicle damage you MUST attach an itemized estimate of damages, attach documentation from your insurance company supporting your claim, or have a repair facility representative verify your damages by completing this section and attach an itemized statement or other supporting documentation. BUSINESS TELEPHONE # ( ) - PARTS $ LABOR DATE TAX TOTAL $ REPAIR FACILITY MANAGER SIGNATURE X your insurance company supporting your claim. DOCTOR NAME ADDRESS DOCTOR SIGNATURE DATE NOTE: Claims cannot be processed without SIGNATURE PERSONAL INJURY: To document personal injury you must have a physician complete this section, or attach documentation from NAME OF INJURED PARTY ADDRESS DESCRIPTION OF INJURIES DRIVER PASSENGER PEDESTRIAN X NUMBER OF DAYS HOSPITALIZED APPROX. AMOUNT OF MED. EXP. PROPERTY DAMAGE: (buildings, signs, poles, trees, shrubs, etc.): Please attach an itemized estimate of repairs, a billing, or documentation from your insurance company supporting your claim. AFTER COMPLETING BOTH SIDES OF THIS FORM, SIGN YOUR NAME DATE X Your signature and the filing of this report is an indication that the driver or owner of the other vehicle did not have insurance or other financial responsibility coverage at the time of this accident. MAIL COMPLETED REPORT TO: BUREAU OF MOTOR VEHICLES ATTN: DRIVER LICENSE SUSPENSIONS P.O. BOX 16583 COLUMBUS, OH 43216-6583 BMV 3303 12/12 [760-0998] Page 2 of 2 PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com
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