Form 1140 - Motor Vehicle Accident Report Page 3
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DOR USE ONLY
FORM
MISSOURI DEPARTMENT OF REVENUE
NAIC NUMBER
ORI NUMBER
CASE NUMBER
DRIVER LICENSE BUREAU
1140
MOTOR VEHICLE ACCIDENT REPORT
(REV. 6-2006)
➞ ➞
STOP
PART 1 — ACCIDENT INFORMATION
ONLY REPORT ACCIDENTS OCCURRING IN MISSOURI
ACCIDENT DATE
TIME
COUNTY
STATE
A.M.
P.M.
ACCIDENT LOCATION - STREET NAME OR HIGHWAY NUMBER
NUMBER OF VEHICLES INVOLVED
WAS A POLICE REPORT MADE?
IF YES, WHAT POLICE AGENCY
YES
NO
PART 2 — YOUR INFORMATION
VEHICLE DRIVER
VEHICLE OWNER
DRIVER’S NAME
SEX
OWNER’S NAME
DATE OF BIRTH
SEX
STREET ADDRESS
STREET ADDRESS
DRIVER LICENSE NUMBER
CITY, STATE
ZIP CODE
CITY, STATE
ZIP CODE
DATE OF BIRTH
DRIVER LICENSE NUMBER
STATE
VEHICLE MAKE/YEAR
MODEL
LICENSE PLATE NUMBER
STATE
INVOLVEMENT (IF OTHER THAN VEHICLE DRIVER/OWNER)
NAME
DATE OF BIRTH
SEX
PASSENGER
PEDESTRIAN
STREET ADDRESS
DRIVER LICENSE NUMBER
PROPERTY OWNER (OTHER THAN VEHICLE)
TYPE OF PROPERTY ______________________
CITY, STATE
ZIP CODE
OTHER __________________________________
YOUR LIABILITY INSURANCE INFORMATION
WAS YOUR VEHICLE COVERED BY LIABILITY INSURANCE AT THE TIME OF THE ACCIDENT?
➞ ➞
YES
NO
STOP
YOU MUST MARK A BOX!
IMPORTANT! IF YOU MARK YES, YOU MUST PROVIDE YOUR INSURANCE COMPANY NAME AND POLICY NUMBER BELOW.
FAILURE TO PROVIDE THIS INFORMATION MAY RESULT IN SUSPENSION ACTION.
INSURANCE COMPANY NAME (NOT AGENCY OR BROKERAGE)
INSURANCE POLICY/CLAIM NUMBER
➞ ➞
STOP
PART 3 — SIGNATURE
YOU MUST SIGN THE REPORT OR IT WILL BE RETURNED TO YOU
I STATE THAT THE INFORMATION ON BOTH SIDES OF THIS REPORT IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
SIGNATURE
I AM:
DRIVER
OWNER
PROPERTY OWNER
ATTORNEY
PASSENGER
PEDESTRIAN
INSURANCE COMPANY REPRESENTATIVE
CORPORATE OFFICER
➞ ➞
COMPLETE REVERSE SIDE
MO 860-0427 (6-2006)
DOR-1140 (6-2006)
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