Form 1140 - Motor Vehicle Accident Report Page 2
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MISSOURI DEPARTMENT OF REVENUE
DRIVER LICENSE BUREAU
1140
MOTOR VEHICLE ACCIDENT REPORT
(REV. 6-2006)
INSTRUCTIONS FOR COMPLETING THIS FORM.
PART 1:
Fill in all blanks with the information requested.
PART 2:
Fill in your vehicle driver and owner information. If the vehicle was parked, write “parked” in the vehicle driver
box and fill in the owner information. If you were not a vehicle driver or owner, mark the correct box under “Your
Involvement” and fill in the information in the spaces provided.
Fill in your liability insurance information and mark the correct box. (This is only required if you are the vehicle
driver and/or owner.)
PART 3:
Sign your name and mark the correct box.
PART 4:
Fill in the driver, owner, and vehicle information for all other involved parties.
PART 5:
Draw a diagram of the accident using the symbols and instructions on the form.
Explain how the accident happened, in your own words.
Attach a denial letter from the uninsured person’s insurance company, if you have one. The letter should state the reason
why coverage was denied for the accident. It must be on the company’s stationery and signed by the person who reviewed
the claim.
PROPERTY DAMAGE AND/OR BODILY INJURY DOCUMENTS
1. In order to determine a percentage of fault and require security for your loss,
both
of the following statements must
apply.
A. There was more than $500 in damage to one or more person’s property, or there was bodily injury or death.
B. It has been less than nine months since the accident happened.
Reason: A notice must be sent to the uninsured person within one year of the accident date. We need 90 days
to process the accident report and determine a percentage of fault for the accident.
2. If statements 1.A and 1.B
do
apply, attach any of the following documents that pertain to this accident.
•
An estimate of repair cost for the vehicle or other property. (It must be readable, itemized, and contain the accident
date or estimate date. It must also contain the name and address of the repair shop or insurance company);
•
A doctor’s report and/or medical bills. (The type of injury must be explained in detail and the service date must be
included. It must also contain the name and address of the healthcare provider); and/or
•
A copy of a death certificate or police report showing there was a death.
3. If statements 1.A. and/or 1.B.
do not
apply, the uninsured person’s driver license and/or plates can be taken away for
not having insurance at the time of the accident. The accident report must be mailed to us within one year of the
accident date.
MAIL THE COMPLETED ACCIDENT REPORT FORM AND ANY ATTACHMENTS TO THE DRIVER LICENSE BUREAU,
P.O. BOX 200, JEFFERSON CITY, MISSOURI 65105-0200, OR FAX TO (573) 526-7365.
MO 860-0427 (6-2006)
DOR-1140 (6-2006)
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