Form Mv-104s - Truck And Bus Supplemental Police Accident Report
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1New York State Department of Motor Vehicles
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TRUCK and BUS SUPPLEMENTAL
Local Codes
POLICE ACCIDENT REPORT
MV-104S (8/14)
o
Mail To: NYS Dept. of Motor Vehicles, Crash Records Center
AMENDED REPORT
PO Box 2084, Albany NY 12220-0084
INSTRUCTIONS You must complete this form:
Number of:
Number of Vehicles:
u
IF at least one of the vehicles involved is:
____ Trucks having a GVWR or
____ Towed/transported from scene
- a truck having a GVWR or GCWR > 10,000 lbs.; or
GCWR > 10,000 lbs.
due to damage
- a vehicle with a HazMat (HM) placard; or
Number of Persons:
- a bus designed to carry 9 or more persons, including the driver;
____ Vehicles with a HazMat (HM)
u
AND at least one of the following conditions is met:
placard
____ Sustaining fatal injuries
- at least one person sustained fatal injuries
- at least one person was transported for IMMEDIATE medical treatment
____ Buses designed to carry 9
____ Transported for IMMEDIATE
or more persons
- at least one vehicle is disabled and was towed/transported from the scene.
medical treatment
MILITARY TIME
CITY/TOWN/VILLAGE
ACCIDENT DATE
COUNTY
Mo.
Day
Year
DRIVER
STATE OF LIC.
LICENSE ID #
DRIVER NAME - exactly as printed on license (Last, First, M.I.)
LICENSE CLASS
1
DATE OF BIRTH
SEX
8
1 A
2 B
3 CDL C
4 D
5 DJ
Mo.
Day
Year
1 Male
2 Female
6 E
7 M
8 MJ
9 OTHER
10 DM
CARRIER NAME
STREET OR P.O. BOX
CITY
STATE
ZIP CODE
TOTAL AXLES
9
(Includes trailers)
PLATE NUMBER
STATE OF REG.
CARRIER’S IDENTIFICATION NUMBERS
US DOT
MC/MX
2
GVWR FOR SINGLE UNIT/GCWR FOR COMBO VEHICLES
VEHICLE IDENTIFICATION NUMBER
1 Less than or equal to 10,000 lbs.
2 10,001 - 26,000 lbs.
3 More than 26,000 lbs.
3
VEHICLE CONFIGURATION
TRAFFIC WAY
10
1 Bus (seats 15 + people, including driver)
8 Tractor/Triples
1 Two-way, not divided
2 Single-unit Truck (2-axle, 6-tire)
9 Unknown Heavy Truck, cannot classify
2 Two-way, divided, unprotected median
3 Single-unit Truck (3 or more axles)
10 Passenger Car - only record when vehicle displays
3 Two-way, divided, positive median barrier
4 Truck/Trailer
a Hazardous Material placard
4 One-way not divided
5 Truck Tractor (bobtail)
11 Light truck (van, mini-van, panel, pickup, sport utility
5 Not reported
vehicle) only record when vehicle displays an HM placard
6 Tractor/Semi-trailer
7 Tractor/Doubles
12 Bus (seats for 9 - 15 people, including driver)
CARGO BODY TYPE
11
4
ACCESS CONTROL
11 Pole
1 Bus (seats 15+ people, including driver)
6 Concrete Mixer
12 Bus (seats 9-15 people, including driver)
2 Van/Enclosed Box
1 No Access Control
7 Auto Transporter
13 Not Applicable/No Cargo Body Type
3 Cargo Tank
2 Full Access Control
8 Garbage/Refuse
14 Intermodal Chassis
4 Flatbed
9 Other
4 Partial Access Control
15 Logging
5 Dump
10 Grain, Chips, Gravel
16 Vehicle Towing Another Motor Vehicle
12
5
CARRIER TYPE
BUS TYPE
5 Charter
3 Not in Commerce (Other Truck/Bus over 10,000 lbs.)
1 Not a Bus
3 Transit
1 Intrastate Carrier
4 Not in Commerce - Government
2 School
4 Intercity
6 Other
2 Interstate Carrier
SEQUENCE OF EVENTS (FOR THIS VEHICLE)
HAZARDOUS MATERIALS INVOLVEMENT
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