REPORT OF A MOTOR VEHICLE CRASH
DEPARTMENT OF MOTOR VEHICLES
Agency of Transportation
120 State Street
Montpelier, Vermont 05603-0001
(voice) 802.828.2000
dmv.vermont.gov
A crash with more than 2 vehicles involved must
fill
out as many forms as needed to include all
vehicles
involved in the crash.
FOR OFFICE USE ONLY
DMV Crash Number
ALL INFORMATION REQUESTED MUST BE COMPLETED IN INK OR TYPEWRITTEN
THE OPERATOR OF EVERY MOTOR VEHICLE INVOLVED IN A CRASH WHICH RESULTS IN INJURY OR DEATH OR TOTAL PROPERTY
DAMAGE OF $3,000.00 OR MORE (THIS INCLUDES ALL VEHICLES INVOLVED AND PHYSICAL PROPERTY DAMAGE), MUST MAKE A REPORT
ON THIS FORM WITHIN 72 HOURS TO THE ABOVE ADDRESS. YOU MUST REPORT EVEN IF VEHICLE WAS PARKED. THE FAILURE OR
REFUSAL OF ANY PERSON TO REPORT MAY BE PUNISHABLE BY A CIVIL PENALTY. INSURANCE INFORMATION IS REQUIRED
TIME OF CRASH
A.M.
P.M.
DAY OF WEEK
MONTH DAY YEAR OF CRASH
/ /
PLACE OF CRASH (CITY OR TOWN)
STREET/ROUTE/HIGHWAY OF CRASH
IF YOUR (OPERATOR #1) ADDRESS IS DIFFERENT FROM THE ADDRESS ON DMV RECORDS AND THIS FORM IS SIGNED BY YOU
THIS FORM WILL BE CONSIDERED TO BE A NOTICE OF ADDRESS CHANGE AND YOUR ADDRESS WILL BE CHANGED ON
DMV RECORDS.
YOUR VEHICLE NUMBER OF OCCUPANTS
OTHER VEHICLE
OR PEDESTRIAN OR BICYCLIST
NUMBER OF OCCUPANTS
OPERATOR NAME: LAST FIRST MIDDLE
STREET OR BOX NO.
CITY OR TOWN
STATE
CITY OR TOWN
STATE
ZIP CODE
DATE OF BIRTH
GENDER
ZIP CODE
DATE OF BIRTH (IF KNOWN)
GENDER (IF KNOWN)
OPERATOR’S LICENSE NO.
CLASS
STATE
OPERATOR’S LICENSE NO. (IF KNOWN)
CLASS (IF KNOWN)
STATE
IDENTIFICATION NUMBER
PLATE NUMBER
PLATE STATE
IDENTIFICATION NUMBER
PLATE NUMBER
PLATE STATE
VEHICLE YEAR
VEHICLE MAKE
VEHICLE MODEL
VEHICLE TYPE
VEHICLE YEAR
VEHICLE MAKE
VEHICLE MODEL
VEHICLE TYPE
TRAILER YEAR
TRAILER MAKE
TRAILER MODEL
TRAILER PLATE #
TRAILER YEAR
TRAILER MAKE
TRAILER MODEL
TRAILER PLATE #
COMMERCIAL
VEHICLE
YES NO
HAZARDOUS
MATERIAL
YES NO
COMMERCIAL
VEHICLE
YES NO
HAZARDOUS
MATERIAL
YES NO
ACTUAL COST
OF VEHICLE #1
REPAIRS
IF THE CRASH INVOLVED A PEDESTRIAN OR A BICYCLIST, COMPLETE
THE FOLLOWING INFORMATION
ACTUAL COST
OF VEHICLE #2
REPAIRS
WHAT WAS PEDESTRIAN OR BICYCLIST DOING
PROPERTY
DAMAGE OTHER
THAN VEHICLE
WALKING WITH TRAFFIC
PLAYING IN ROAD
UNKNOWN
PROPERTY
DAMAGE OTHER
THAN VEHICLE
WALKING AGAINST TRAFFIC
GETTING ON/OFF VEHICLE
NOT IN ROADWAY
PUSHING VEHICLE
APPROXIMATE
COST OF
PROPERTY
REPAIRS
CROSSING INTERSECTION
WORKING ON VEHICLE
APPROXIMATE
COST OF
PROPERTY
REPAIRS
CROSSING NOT AT AN
INTERSECTION
RIDING/PUSHING BIKE
OTHER:
PROPERTY OWNER’S NAME
AND ADDRESS:
PROPERTY OWNER’S NAME
AND ADDRESS:
DESCRIBE INJURY:
OCCUPANT DATA
THE INFORMATION BELOW IS REQUIRED FOR YOURSELF AND ALL OCCUPANTS IN ALL VEHICLES
(ATTACH ADDITIONAL SHEETS IF THERE IS NOT ENOUGH ROOM BELOW)
OCCUPANT’S NAME AND ADDRESS
(USE THE FIRST LINE FOR YOURSELF EVEN IF NOT
INJURED
NATURE AND EXTENT OF
INJURY
(STATE “NONE” IF NOT INJURED)
NAME OF HOSPITAL
INJURED TAKEN TO
THIS INFORMATION IS REQUIRED
VEH
NO
POSITION
WITHIN
VEHICLE
AGE
OF
OCC.
GENDER
WAS
SEATBELT
OR
HARNESS
USED
WAS
OCCUPANT
THROWN
FROM
VEHICLE
1
YOURSELF
DRIVER
CO
NTINUE ON NEXT PAGE
DESCRIBE IN YOUR OWN WORDS WHAT HAPPENED (ATTACH SHEET IF NECESSARY)
WAS THIS CRASH INVESTIGATED BY AN OFFICER?
Yes No
IF YES, GIVE NAME OF OFFICER:
OFFICER’S DEPARTMENT:
WERE YOU DRIVING A COMMERCIAL VEHICLE? Yes No
WAS THE VEHICLE TRANSPORTING HAZARDOUS MATERIALS?
Yes
No
IF YES, GIVE NAME OF MATERIAL
OPERATOR SIGN HERE
Date of Report
CONTINUE ON NEXT PAGE
IMPORTANT: You must furnish the insurance information requested for the vehicle you were operating.
Vermont law requires that any per
son involved in a crash which has resulted in bodily injury or death to any person or whereby the motor vehicle
then under his control or any other property is damaged in an aggregate amount to the extent of $3,000 or more must furnish the commissioner
with satisfactory proof that a standard provisions automobile liability insurance policy was in full force and effect at the time of the crash.
Any person who fails to furnish satisfactory proof that liability insurance was in force at the time of the crash may be required to obtain and
furnish proof that Financial Responsibility Insurance has been obtained covering such person in the future operation of any motor vehicle.
(OPERATOR #1) MUST COMPLETE BOTH SECTIONS BELOW IN FULL. IF YOU FAIL TO GIVE FULL INFORMATION
BELOW, IT WILL BE ASSUMED THAT YOU DO NOT HAVE AUTOMOBILE LIABILITY INSURANCE AND A
SUSPENSION OF YOUR LICENSE/PRIVILEGE TO OPERATE IN VERMONT WILL BE ISSUED.
DMV CRASH NUMBER
Was an Automobile Liability Insurance policy, providing you AT LEAST $25,000/$50,000 bodily injury and $10,000
property
damage insurance in effect on the date of the above crash? You must answer Yes or No.
Yes
No
Name of your (Operator 1) Insurance Company (NOT AGENT):
Insurance Company Mailing Address:
Policy Number:
Policy Period From:
to
Name of Policy Holder:
Address
Name of Operator at the time of the Crash:
Date of Crash:
Is this motor vehicle covered by a Certificate of Self-Insurance? Yes No If yes, certificate number:_____________
DO NOT DETACH FORM SR-21A
VERMONT DEPARTMENT OF MOTOR VEHICLES
DMV CRASH NUMBER
Name of insurance company with whom you are insured for liability or damage to others (For Operator #1):
Insurance Company mailing
address:
Policy Number:
Policy Period From:
to
Date of Crash:
At or near (Town/City):
Make of your vehicle:
Year:
Type:
VIN:
Operator:
Address:
Name of Policy Holder:
Signature of Operator:
IMPORTANT! ! THIS CRASH SHOULD ALSO BE REPORTED DIRECTLY TO YOUR INSURANCE COMPANY. FAILURE TO REPORT MAY
JEOPARDIZE YOUR AUTOMOBILE LIABILITY
DO NOT WRITE IN THE SECTION BELOW – IT IS FOR USE OF INSURANCE COMPANY ONLY
TO INSURANCE COMPANY
Return this form within 15 days if no policy, or insufficient policy was in effect as alleged by motorist. If notification is not received within 15 days, it will
be assumed the required insurance was in effect at the time of the crash. Send to :
COMMISSIONER OF MOTOR VEHICLES, 120 STATE STREET, MONTPELIER, VERMONT 05603-0001
With regard to an insurance policy for the policy holder named on the reverse side hereof the undersigned insurance company advises you in accordance
w
ith the items checked below :
1. No such policy was in effect at the time of the crash.
2
. Our policy affords limits of liability less than $25,000/$50,000 bodily injury and $10,000 property damage (indicate actual limits under remarks).
REMARKS :
NAME OF INSURANCE COMPANY:
AUTHORIZED REPRESENTATIVE:
DATE :
VA-004 09/2019 MTC