Form Mv-104en - Early Notification Of A Fatal Accident

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EARLY NOTIFICATION OF A FATAL ACCIDENT
INSTRUCTIONS:
This form must be completed and either faxed to (518) 474-7302 or emailed to NYSfatals@dmv.ny.gov within 24
hours from the date of every fatal accident that occurs in NYS. DMV is responsible for implementing this new Early
Notification Program as part of our federal accident reporting requirements. Please remember to submit separately to
DMV a completed accident report (the “Police Accident Report,” form MV-104AN or form MV-104A) along with
the “Police Report for Fatal Motor Vehicle Accidents,” form MV-104D and, if applicable, the “Truck & Bus
Supplemental Report,” form MV-104S.
ACCIDENT INFORMATION:
Date of Accident
Time of Accident
Number of Fatalities
County of Accident
Number of
Number of Pedestrians or
Was a Commercial
Was Alcohol
Vehicles Involved
Bicyclist Involved
Vehicle Involved?
Involvement Suspected?
o
o
o
o
Yes
No
Yes
No
DECEASED INFORMATION:
Name of Deceased
Date of Death
LAW ENFORCEMENT INFORMATION:
NCIC CODE:
LOCAL CODE:
PRECINCT:
ACCIDENT NUMBER:
(NYC Only)
(NYC Only)
REPORTING OFFICER’S NAME:
CONTACT TELEPHONE NUMBER:
MV-104EN (3/17)
reset/clear

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