Form 5179 - Motor Vehicle Accident Case Status Request
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Form
Missouri Department of Revenue
5179
Motor Vehicle Accident Case Status Request
Do not complete this form to report a motor vehicle accident.
Complete Form 1140, Motor Vehicle Accident Report located at dor.mo.gov.
Accident Case Number
Accident Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Vehicle Driver
Vehicle Owner
Driver’s Name (Last, First, Middle)
Owner’s Name (Last, First, Middle)
Street Address
Street Address
City, State
Zip Code
City, State
Zip Code
Date of Birth (MM/DD/YYYY)
Date of Birth (MM/DD/YYYY)
Driver License Number
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
Driver License Number
State
Vehicle Make and Year
License Plate Number
State
Name (Last, First, Middle)
Sex
r
Passenger
r
Street Address
Zip Code
Pedestrian
r
Property Owner (Other Than Vehicle)
City, State
_______________________
Type of Property
r
Driver License Number
Date of Birth (MM/DD/YYYY)
_____________________________
Other:
___ ___ / ___ ___ / ___ ___ ___ ___
E-mail Address
Attention
r
Insurance Agency
__________________
Policy or Claim Number
Name
r
Attorney
Street Address
City, State
r
Other:
___________________________________
________________________________________________
Zip Code
Telephone Number
( __ __ __ ) __ __ __ - __ __ __ __
You may submit this form by mail, fax or e-mail.
Form 5179 (Revised 06-2013)
Mail to:
Driver License Bureau
Phone: (573) 751-7195
P.O. Box 200
Fax: (573) 526-7365
Jefferson City, MO 65105-0200
E-mail: dlbmail@dor.mo.gov
Submit form by e-mail
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