The Vermont Report Form is a document required by the Vermont Department of Motor Vehicles for reporting motor vehicle crashes that result in injury, death, or property damage exceeding $3,000. All operators involved in such incidents must complete this form within 72 hours, ensuring that all requested information is provided in full. Failure to report may lead to civil penalties, making timely submission essential for compliance.
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The Vermont Report form is a crucial document for anyone involved in a motor vehicle crash in the state. This form must be filled out when a crash results in injury, death, or property damage exceeding $3,000. It’s important to complete the report within 72 hours of the incident. Whether you were driving, a passenger, or even if your vehicle was parked, you need to report the crash. The form requires detailed information, including the time and location of the crash, the identities of all operators involved, and specifics about the vehicles. If there were pedestrians or bicyclists involved, additional information is also necessary. Each operator must provide proof of insurance, as Vermont law mandates that adequate liability coverage be in place at the time of the crash. Failing to report or provide this information can lead to civil penalties. Completing the form accurately is essential for both legal compliance and for ensuring that all parties involved can address any damages or injuries that may arise from the incident.
REPORT OF A MOTOR VEHICLE CRASH
DEPARTMENT OF MOTOR VEHICLES
FOR OFFICE USE ONLY
Agency of Transportation
A crash with more than 2 vehicles involved must fill
DMV Crash Number
120 State Street
out as many forms as needed to include all vehicles
Montpelier, Vermont 05603-0001
involved in the crash.
(voice) 802.828.2050
dmv.vermont.gov
ALL INFORMATION REQUESTED MUST BE COMPLETED IN FULL IN INK OR TYPEWRITTEN
THE OPERATOR OF EVERY MOTOR VEHICLE INVOLVED IN A CRASH WHICH RESULTS IN INJURY OR DEATH OR TOTAL PROPERTY DAMAGE OF $3,000.00 OR MORE, MUST MAKE A REPORT ON THIS FORM WITHIN 72 HOURS TO THE ABOVE ADDRESS. YOU MUST REPORT EVEN IF VEHICLE WAS PARKED. THE FAILURE OR REFUSAL OF ANY PERSON TO REPORT MAY BE PUNISHABLE BY A CIVIL PENALTY.
TIME OF CRASH DAY OF WEEK
A.M.
P.M.
MONTH/DAY/YEAR OF CRASH
PLACE OF CRASH (CITY OR TOWN)
STREET/ROUTE/HIGHWAY OF CRASH
IF YOUR (OPERATOR #1) ADDRESS IS DIFFERENT FROM THE ADDRESS ON DMV RECORDS AND THIS FORM IS SIGNED BY YOU THIS FORM
WILL BE CONSIDERED TO BE A NOTICE OF ADDRESS CHANGE AND YOUR ADDRESS WILL BE CHANGED ON DMV RECORDS.
YOUR VEHICLE ~ NO. 1
NUMBER OF OCCUPANTS
OTHER VEHICLE ~ NO. 2
OR PEDESTRIAN OR BICYCLIST
OPERATOR NAME: LAST
FIRST
MIDDLE
STREET OR BOX NO.
CITY OR TOWN
STATE
ZIP CODE
DATE OF BIRTH
GENDER
OPERATOR’S LICENSE NO.
CLASS
IDENTIFICATION NUMBER
PLATE NUMBER
PLATE STATE
VEHICLE YEAR
VEHICLE MAKE
VEHICLE MODEL
VEHICLE TYPE
TRAILER YEAR
TRAILER MAKE
TRAILER MODEL
TRAILER PLATE #
COMMERCIAL
YES
NO
HAZARDOUS
VEHICLE
MATERIAL
ACTUAL COST
IF THE CRASH INVOLVED A PEDESTRIAN OR A BICYCLIST, COMPLETE
OF VEHICLE #1
THE FOLLOWING INFORMATION
OF VEHICLE #2
REPAIRS
WHAT WAS PEDESTRIAN OR BICYCLIST DOING
PROPERTY
WALKING WITH TRAFFIC
PLAYING IN ROAD
UNKNOWN
WALKING AGAINST TRAFFIC
GETTING ON/OFF VEHICLE
DAMAGE OTHER
THAN VEHICLE
NOT IN ROADWAY
PUSHING VEHICLE
APPROXIMATE
CROSSING INTERSECTION
WORKING ON VEHICLE
COST OF
CROSSING NOT AT AN
RIDING/PUSHING BIKE
INTERSECTION
OTHER:
PROPERTY OWNER’S NAME
AND ADDRESS:
DESCRIBE INJURY:
OCCUPANT DATA
THE INFORMATION BELOW IS REQUIRED FOR YOURSELF AND ALL OCCUPANTS IN ALL VEHICLES
(ATTACH ADDITIONAL SHEETS IF THERE IS NOT ENOUGH ROOM BELOW)
THIS INFORMATION IS REQUIRED
OCCUPANT’S NAME AND ADDRESS
NATURE AND EXTENT OF
NAME OF HOSPITAL
WAS
POSITION
AGE
SEATBELT
OCCUPANT
(USE THE FIRST LINE FOR YOURSELF EVEN IF NOT
INJURY
INJURED TAKEN TO
VEH
WITHIN
OF
OR
THROWN
INJURED
(STATE “NONE” IF NOT INJURED)
OCC.
HARNESS
FROM
USED
1
YOURSELF
DRIVER
CONTINUE ON NEXT PAGE
TA-VA-04 (d) INTERNET 04/2012 REB
DESCRIBE IN YOUR OWN WORDS WHAT HAPPENED (ATTACH SHEET IF NECESSARY)
WAS THIS CRASH INVESTIGATED BY AN OFFICER?
IF YES, GIVE NAME OF OFFICER:
OFFICER’S DEPARTMENT:
WERE YOU DRIVING A COMMERCIAL VEHICLE?
Yes
No
WAS THE VEHICLE TRANSPORTING HAZARDOUS MATERIALS?
IF YES, GIVE NAME OF MATERIAL
DATE OF REPORT
OPERATOR SIGN HERE
IMPORTANT: YOU MUST FURNISH THE INSURANCE INFORMATION REQUESTED.
Vermont law requires that any person involved in a crash which has resulted in bodily injury or death to any person or whereby the motor vehicle then under his control or any other property is damaged in an aggregate amount to the extent of $3,000 or more must furnish the commissioner with satisfactory proof that a standard provisions automobile liability insurance policy was in full force and effect at the time of the crash.
Any person who fails to furnish satisfactory proof that liability insurance was in force at the time of the crash may be required to obtain and furnish proof that Financial Responsibility Insurance has been obtained covering such person in the future operation of any motor vehicle.
(OPERATOR #1) MUST COMPLETE BOTH SECTIONS BELOW IN FULL. IF YOU FAIL TO GIVE FULL INFORMATION BELOW, IT WILL BE ASSUMED THAT YOU DO NOT HAVE AUTOMOBILE LIABILITY INSURANCE AND A SUSPENSION OF YOUR LICENSE/PRIVILEGE TO OPERATE IN VERMONT WILL BE ISSUED.
DMV CRASH NUMBER
Was an Automobile Liability Insurance policy, providing you AT LEAST $25,000/$50,000 bodily injury and $10,000 property
damage insurance in effect on the date of the above crash? You must answer Yes or No.
Name of your (Operator 1) Insurance Company (NOT AGENT):
Insurance Company Mailing
Address:
Policy Number:
Policy Period From:
to
Name of Policy Holder:
Name of Operator at the time of the Crash:
Date of Crash:
Is this motor vehicle covered by a Certificate of Self-Insurance?
If yes, certificate number:
DO NOT DETACH FORM SR-21A
VERMONT DEPARTMENT OF MOTOR VEHICLES MONTPELIER VERMONT
VERMONT
Name of insurance company with whom you are insured for liability or damage to others (For Operator #1):
Insurance Company mailing address:
At or near (Town/City):
Make of your vehicle:
Year:
Type:
VIN:
Operator:
Signature of Operator:
IMPORTANT! ! THIS CRASH SHOULD ALSO BE REPORTED DIRECTLY TO YOUR INSURANCE COMPANY. FAILURE TO REPORT MAY JEOPARDIZE YOUR AUTOMOBILE LIABILITY
DO NOT WRITE IN THE SECTION BELOW – IT IS FOR USE OF INSURANCE COMPANY ONLY
TO INSURANCE COMPANY :
Return this form in 15 days if no policy, or insufficient policy was in effect as alleged by motorist. IF NOTIFICATION IS NOT RECEIVED WITHIN 15 DAYS,
IT WILL BE ASSUMED THE REQUIRED INSURANCE WAS IN EFFECT AT THE TIME OF THE CRASH.
TO COMMISSIONER OF MOTOR VEHICLES, MONTPELIER, VERMONT 05603-0001
With regard to an insurance policy for the policy holder named on the reverse side hereof the undersigned insurance company advises you in accordance with the items checked below :
1.No such policy was in effect at the time of the crash.
2.Our policy applies to the owner of the vehicle but does not apply to the operator of the vehicle involved in the crash.
3.Our policy affords limits of liability less than $25,000/$50,000 bodily injury and $10,000 property damage (indicate actual limits under remarks).
REMARKS :
NAME OF INSURANCE COMPANY :
BY :
DATE :
AUTHORIZED REPRESENTATIVE
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