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Accident Report For School Vehicles Transporting Pupils Teachers Supervisors MV-104F - New York

Accident Report For School Vehicles Transporting Pupils Teachers Supervisors Form. This is a New York form and can be used in Department Of Motor Vehicles Statewide .
 Fillable pdf Last Modified 4/13/2016
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ACCIDENT REPORT FOR SCHOOL VEHICLES TRANSPORTING PUPILS/TEACHERS/SUPERVISORS BEFORE COMPLETING THIS FORM, READ THE INSTRUCTIONS IN SECTION A ON PAGE 6 Accident Date Month Day Day of Week Year Time MV-104F (4/16) PAGE 1 OF 7 Page ______ of ______ 1 o AM Vehicles o PM State of License Number of Left Scene Did police investigate If Yes, Name of Police Agency accident at scene? o Yes o No o Ê DRIVER DRIVER OFVEHICLE 1 Driver License ID Number o VEHICLE 2 o PEDESTRIAN o BICYCLIST o OTHER PEDESTRIAN State of License 2 Driver License ID Number Last Name of Driver 1 First Name M.I. Last Name of Driver 2 First Name M.I. Mailing Address (Include Number & Street) City or Town State Zip Code Apt. No. Mailing Address (Include Number & Street) City or Town State Zip Code Apt. No. Date of Birth Sex Month Day Year Ë REGISTRANT oM oF Date of Birth Month Day No. of Occupants Sex Year Date of Birth Month Day Year Sex oM oF Date of Birth Month Day No. of Occupants Sex Year Apt. No. 3 Name - exactly as printed on registration Mailing Address (Include Number & Street) Name - exactly as printed on registration Apt. No. Mailing Address (Include Number & Street) City or Town State Zip Code City or Town State Zip Code 4 Plate Number State of Reg. Vehicle Year & Make Vehicle Type Plate Number State of Reg. o Regular o Sub Vehicle Year & Make Vehicle Type SCHOOL/ VEHICLE Ì Í Public School District Name Private School System Name Bus Driver: Bus Capacity # of Years of Experience Driving School Bus _____________ Training: o Basic p Advanced How many people were standing on the bus? 5 6 Enter the diagram number from below that describes the accident;_________ Describe damage to Vehicle 1 or draw your own diagram in the space provided (9). Number the vehicles. Estimated Cost of Repairs o $1001 to $1500 Your vehicle is No. 1. ACCIDENT DIAGRAM o $1501 to $2000 o $2001 to $2500 o Over $2500 Rear End Left Turn Right Angle Right Turn Head On 1. 3. 5. Right Turn 7. Sideswipe (opposite direction) 8. Describe damage to Vehicle 2 o $1001 to $1500 Estimated Cost of Repairs o $1501 to $2000 o $2001 to $2500 o Over $2500 7 23 VEHICLE DAMAGE Sideswipe Left Turn (same direction) 2. 0. 4. 6. 24 25 Î ACCIDENT LOCATION County of Accident Route No. or Street Name 9. o City o Town of o Village Nearest Intersecting Route/Street o Miles o N oE o Feet oS o W of o At Intersection With 26 Route No. or Street Name 27 Accident Description (Give your own version) Ï INSURANCE Identify Damaged Property Other Than Vehicle(s) Name of Insurance Company Which Issued Policy Policy Number 28 Name and Address of Policyholder Policy Period From To 29 If Vehicle was Operated Under Permit of ICC or NYS DOT, Give No. Name and Address of Permit Holder VIN If Self-Insured, give Certificate No. and State 30 Date Print Name of Driver (or Representative*) of Vehicle 1 Signature of Driver (or Representative*) of Vehicle 1 ç 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. * o Injury o 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 and/or registration. American LegalNet, Inc. www.FormsWorkFlow.com COPY 1: COMMISSIONER OF MOTOR VEHICLES ACCIDENT REPORT FOR SCHOOL VEHICLES TRANSPORTING PUPILS/TEACHERS/SUPERVISORS BEFORE COMPLETING THIS FORM, READ THE INSTRUCTIONS IN SECTION A ON PAGE 6 Accident Date Month Day Day of Week Year Time MV-104F (4/16) PAGE 2 OF 7 Page ______ of ______ 1 o AM Vehicles o PM State of License Number of Left Scene Did police investigate If Yes, Name of Police Agency accident at scene? o Yes o No o Ê DRIVER DRIVER OFVEHICLE 1 Driver License ID Number o VEHICLE 2 o PEDESTRIAN o BICYCLIST o OTHER PEDESTRIAN State of License 2 Driver License ID Number Last Name of Driver 1 First Name M.I. Last Name of Driver 2 First Name M.I. Mailing Address (Include Number & Street) City or Town State Zip Code Apt. No. Mailing Address (Include Number & Street) City or Town State Zip Code Apt. No. Date of Birth Sex Month Day Year Ë REGISTRANT oM oF Date of Birth Month Day No. of Occupants Sex Year Date of Birth Month Day Year Sex oM oF Date of Birth Month Day No. of Occupants Sex Year Apt. No. 3 Name - exactly as printed on registration Mailing Address (Include Number & Street) Name - exactly as printed on registration Apt. No. Mailing Address (Include Number & Street) City or Town State Zip Code City or Town State Zip Code 4 Plate Number State of Reg. Vehicle Year & Make Vehicle Type Plate Number State of Reg. o Regular o Sub Vehicle Year & Make Vehicle Type SCHOOL/ VEHICLE Ì Í Public School District Name Private School System Name Bus Driver: Bus Capacity # of Years of Experience Driving School Bus _____________ Training: o Basic p Advanced How many people were standing on the bus? 5 6 Enter the diagram number from below that describes the accident;_________ Describe damage to Vehicle 1 or draw your own diagram in the space provided (9). Number the vehicles. Estimated Cost of Repairs o $1001 to $1500 Your vehicle is No. 1. ACCIDENT DIAGRAM o $1501 to $2000 o $2001 to $2500 o Over $2500 Rear End Left Turn Right Angle Right Turn Head On 1. 3. 5. Right Turn 7. Sideswipe (opposite direction) 8. Describe damage to Vehicle 2 o $1001 to $1500 Estimated Cost of Repairs o $1501 to $2000 o $2001 to $2500 o Over $2500 7 23 VEHICLE DAMAGE Sideswipe Left Turn (same direction) 2. 0. 4. 6. 24 25 Î ACCIDENT LOCATION County of Accident Route No. or Street Name 9. o City o Town of o Village Nearest Intersecting Route/Street o Miles o N oE o Feet oS o W of o At Intersection With 26 Route No. or Street Name 27 Accident Description (Give your own version) Ï INSURANCE Identify Damaged Property Other Than Vehicle(s) Name of Insurance Company Which Issued Policy Policy Number 28 Name and Address of Policyholder Policy Period From To 29 If Vehicle was Operated Under Permit of ICC or NYS DOT, Give No. Name and Address of Permit Holder VIN If Self-Insured, give Certificate No. and State 30 Date Print Name of Driver (or Representative*) of Vehicle 1 Signature of Driver (or Representative*) of Vehicle 1 ç 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. * o Inj
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