STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DIVISION OF MOTOR VEHICLES – ACCIDENT OFFICE
600 New London Avenue, Cranston, RI 02920-3024
Phone: 401-462-4368 |
www.dmv.ri.gov |
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USE BLUE OR BLACK INK ONLY |
Motor Vehicle Accident Report
FOR DMV USE ONLY
CASE NO.
If your accident involved an UNINSURED MOTORIST, please include with your report an itemized estimate of damage to your vehicle and/or property and any medical bills and/or lost wages. DO NOT SUBMIT AN ITEMIZED ESTIMATE if all vehicles involved in the accident are insured. (read below for more information)
If you were directly or indirectly involved in a motor vehicle accident, you must submit one or more of the following (if applicable) pursuant to R.I.G.L. § 31-31 “Safety Responsibility Administration – Security Following Accident”:
If there was damage to your vehicle and the amount of damage is in excess of $1000.00 you must provide any and all documents to this department (i.e. itemized estimates of repair, completed and signed by the repair shop and/or a letter from an insurance company, if vehicle was totaled). Please make sure that the repair estimate includes make, model and year of the vehicle, as well as the VIN. Also include the date and location of the accident.
If there was damage to your property (non-vehicle) and the amount of damage is in excess of $1000.00 you must provide any and all documents to this department (i.e itemized estimates of repair, including materials and labor; copy of all receipts for expenses incurred to repair property damaged, and any other documents you feel are necessary). Also include the date and location of the accident (address), and include the type of property damaged (i.e. mailbox, fence, building, etc).
If you, as an operator, passenger or pedestrian, incurred medical expenses as a result of an injury stemming from an accident please provide an attending physician report detailing the description of injuries, probable period of disability, whether or not hospitalization was needed and the total estimated expenses, including fees. The Division of Motor Vehicles Accident Office also will accept alternative rehabilitative statements/bills (i.e. physical therapy).
In addition to providing an attending physician report, if you have experienced the loss of wages as a result of a motor vehicle accident you must provide verification of loss of wages from your employer which details number of hours missed, hourly rate or salary, and a calculated estimate of wages lost per time period stated. The report from your employer should contain the follo wing information: Name, address, gender, age and occupation of injure d and the em ployer’s name, title, address, contact phone number and signature. The Division of Motor Vehicles Accident Office will not accept this form unless it is also signed by the injured party.
MOTOR VEHICLE ACCIDENT REPORT -- INSTRUCTIONS
OTHER VEHICLE YOUR VEHICLE LOCATION AND TIME
Instructions for completing the accident report:
1.Print in all areas required, except for signatures.
2.Answer all questions to the best of your knowledge. Give facts only. Do not guess or assume.
3.When multiple choices are provided, select the best choice.
4.When reporting, enter YOUR information under “YOUR VEHICLE” and the other driver’s information under “OTHER VEHICLE.”
5.If more than two (2) vehicles were involved, more than two (2) persons were injured or property belonging to more than one person was damaged, use an additional accident report to complete the appropriate sections.
6.Print one letter per box. Leave a blank in one box between each word. Do not use periods of commas.
7.Please remember to SIGN the accident report.
8.IF YOU ARE MAILING IN YOUR REPORT: Make sure the report is securely sealed in an envelope and
mail it to the RI DMV, located at 600 New London Avenue, Cranston, RI 02920-3024, Attention: Accident Office
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MONTH |
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YEAR |
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DAY OF WEEK |
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HOUR |
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MIN |
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TOTAL |
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TOTAL |
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TOTAL |
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MONDAY |
THURSDAY SUNDAY |
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TUESDAY |
FRIDAY |
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VEHICLES |
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INJURED |
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PEDESTRIANS |
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PM |
INVOLVED |
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INVOLVED |
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INVOLVED |
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WEDNESDAY |
SATURDAY |
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ACCIDENT OCCURRED ON (PRINT NAME OF STREET OR HIGHWAY) |
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IF NOT AN INTERSECTION |
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HOW MANY FEET FROM NEAREST INTERSECTION ? |
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ACCIDENT OCCURRED IN |
(NAME OF CITY OR TOWN) |
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IN WHAT DIRECTION ? |
N |
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W |
FROM |
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IF AT INTERSECTION (NAME OF INTERSECTING STREET OR HIGHWAY) |
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NAME NEAREST INTERSECTING STREET OR HIGHWAY |
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OPERATOR’S NAME (FIRST, MIDDLE INITIAL, LAST) |
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DATE OF BIRTH |
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SEX |
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OPERATOR’S LICENSE NUMBER |
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STATE |
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DIRECTION |
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MO |
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DAY |
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YEAR |
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M |
F |
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OF TRAVEL |
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N |
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RESIDENCE ADDRESS (NUMBER & STREET, CITY OR TOWN, STATE & ZIP CODE) |
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VEHICLE PLATE NUMBER AND STATE |
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TELEPHONE |
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S |
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E |
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VEHICLE OWNER (COMPLETE NAME & ADDRESS) |
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OWNER’S LICENSE NUMBER |
VEHICLE IDENTIFICATION NUMBER (VIN) |
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W |
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OWNER’S DATE OF BIRTH |
VEHICLE MAKE |
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VEHICLE MODEL |
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YEAR |
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REGISTRATION CLASSIFICATION |
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TELEPHONE |
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MO |
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DAY |
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YEAR |
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(PASSENGER, COMMERCIAL, |
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MOTORCYCLE, CAMPER, ETC.) |
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OPERATOR’S NAME (FIRST, MIDDLE, LAST) |
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DATE OF BIRTH |
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SEX |
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OPERATOR’S LICENSE NUMBER |
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STATE |
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DIRECTION |
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MO |
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DAY |
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YEAR |
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M |
F |
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OF TRAVEL |
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N |
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RESIDENCE ADDRESS (NUMBER & STREET, CITY OR TOWN, STATE & ZIP CODE) |
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VEHICLE PLATE NUMBER AND STATE |
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TELEPHONE |
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S |
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E |
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VEHICLE OWNER (COMPLETE NAME & ADDRESS – LINE 1) |
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VEHICLE IDENTIFICATION NUMBER (VIN) |
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W |
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(NAME & ADDRESS – LINE 2, IF NEEDED) |
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VEHICLE MAKE |
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VEHICLE MODEL |
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YEAR |
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REGISTRATION CLASSIFICATION |
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TELEPHONE |
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(PASSENGER, COMMERCIAL, |
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MOTORCYCLE, CAMPER, ETC.) |
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NON-VEHICLE PROPERTY DAMAGE
OWNER’S NAME |
OWNER’S ADDRESS (NUMBER & STREET, CITY OR TOWN, STATE & ZIP CODE) |
APPROXIMATE COST TO REPAIR |
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APPROXIMATE COST TO REPAIR |
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YOUR VEHICLE (VEHICLE 1) |
$ ____________________ |
OTHER VEHICLE (VEHICLE 2) |
$ ____________________ |
INJURED
ACCIDENT CONDITIONS
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NAME $1'$''5(66OF INJURED (FIRST, MIDDLE INITIAL, LAST) |
NUMBER & STREET |
CITY/TOWN |
STATE ZIP |
INJURED WAS RIDING |
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IN VEHICLE # |
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AGE |
SEX |
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ACCIDENT SEVERITY CONDITION AT SCENE OF ACCIDENT |
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PERSON INJURED |
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M |
F |
1 |
FATAL |
3 |
BRUISES OR ABRASIONS |
1 |
PEDESTRIAN |
5 |
VEHICLE OPERATOR |
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2 |
PEDALCYCLIST |
6 |
VEHICLE PASSENGER |
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2 |
BLEEDING OR BROKEN BONES |
4 |
COMPLAINT OF PAIN |
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3 |
PASSENGER IN BUS |
7 |
MOTORCYCLE OPERATOR |
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4 |
OTHER |
8 |
MOTORCYCLE PASSENGER |
NAME AND ADDRESS OF INJURED (FIRST, MIDDLE INITIAL, LAST)180%(5 |
675((7CITY/TOWN |
STATE=,3 |
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INJURED WAS RIDING |
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IN VEHICLE # |
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AGE |
SEX |
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ACCIDENT SEVERITY CONDITION AT SCENE OF ACCIDENT |
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PERSON INJURED |
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M |
F |
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1 |
FATAL |
3 |
BRUISES OR ABRASIONS |
1 |
PEDESTRIAN |
5 |
VEHICLE OPERATOR |
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2 |
PEDALCYCLIST |
6 |
VEHICLE PASSENGER |
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2 |
BLEEDING OR BROKEN BONES |
4 |
COMPLAINT OF PAIN |
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3 |
PASSENGER IN BUS |
7 |
MOTORCYCLE OPERATOR |
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4 |
OTHER |
8 |
MOTORCYCLE PASSENGER |
ACCIDENT INVOLVED COLLISION WITH ...
1 |
PEDESTRIAN |
4 |
MOVING VEHICLE |
7 |
FIXED OBJECT |
10 OTHER _______________ |
2 |
PEDALCYCLE |
5 |
VEHICLE STOPPED IN ROAD |
8 |
OBJECT IN ROAD |
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3 |
NO COLLISION – RAN OFF ROAD |
6 |
PARKED MOTOR VEHICLE |
9 |
NO COLLISION - OVERTURNED |
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IN YOUR OWN WORDS, PLEASE DESCRIBE WHAT HAPPENED ...
I, THE UNDERSIGNED, DECLARE UNDER PENALTY OF PERJURY THAT ALL STATEMENTS MADE ON THIS REPORT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
OPERATOR’S SIGNATURE(THIS REPORT MUST BE SIGNED): |
PRINT YOUR NAME: |
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YOUR INSURANCE |
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INFORMATION |
WAS YOUR VEHICLE OR |
NAME OF YOUR INSURANCE COMPANY (NOT AGENT) |
POLICY NUMBER |
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THE VEHICLE YOU WERE |
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OPERATING INSURED |
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(LIABILITY INSURANCE) |
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AT THE TIME OF |
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THE ACCIDENT? |
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IF “YES”, COMPLETE |
NAME OF POLICYHOLDER |
STREET ADDRESS |
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ATTACHED FORM |
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YES |
NO |
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DATE: |
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POLICY EFFECTIVE DATES |
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FROM: __________________________ |
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TO: _________________________ |
CITY/TOWN |
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YOUR MOTOR VEHICLE INSURANCE INFORMATION
DATE OF ACCIDENT: |
PLACE OF ACCIDENT: |
FOR DMV USE ONLY
CASE NO.
DESCRIPTION OF VEHICLE INVOLVED IN ACCIDENT MUST CORRESPOND TO “YOUR VEHICLE” ON ACCIDENT REPORT
VEHICLE MAKE: |
TYPE: |
YEAR: |
VIN: |
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NAME OF OPERATOR: |
STREET ADDRESS: |
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CITY / TOWN: |
STATE / ZIP: |
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NAME OF OWNER: |
STREET ADDRESS: |
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CITY / TOWN: |
STATE / ZIP: |
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NAME OF INSURANCE COMPANY (NOT AGENT): |
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POLICY NUMBER: |
EFFECTIVE PERIOD: |
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FROM: ____________________ |
TO: ____________________ |
NAME OF POLICYHOLDER: |
STREET ADDRESS: |
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CITY / TOWN: |
STATE / ZIP: |
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NAME OF INSURANCE AGENT |
STREET ADDRESS: |
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CITY / TOWN: |
STATE / ZIP: |
WHO ISSUED POLICY: |
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YOUR SIGNATURE: |
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DATE SIGNED: |
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FOR USE BY INSURANCE COMPANY ONLY - DO NOT WRITE IN THIS AREA
RETURN THIS FORM ONLY IF NO STANDARD POLICY WAS IN EFFECT AS ALLEGED BY MOTORIST
WITH REGARD TO AN AUTOMOBILE LIABILITY INSURANCE POLICY FOR THE POLICYHOLDER NAMED ON THE REVERSE SIDE HEREOF, THE UNDERSIGNED INSURANCE COMPANY ADVISED YOU IN ACCORDANCE WITH THE ITEMS CHECKED BELOW:
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No policy was in effect on the date of the accident. |
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2 |
Our policy for the named policyholder applies to him/her as the operator but it does not apply to the owner of the vehicle involved in the accident. |
3 |
Our policy applies to the owner of the vehicle, but does not apply to the operator of the vehicle involved in the accident. |
4 |
Our policy affords bodily injury coverage only. |
Remarks: |
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5 |
Our policy affords property damage coverage only. |
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To: STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DIVISION OF MOTOR VEHICLES
600 NEW LONDON AVENUE
CRANSTON, RI 02920-3024
DATE: _______________________________________
Name of Insurance Company
By:
Authorized Representative