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In Vermont, when an individual is involved in a motor vehicle crash that results in injury, death, or total property damage of $3,000.00 or more, they are required to fill out a Detailed Report Form and submit it to the Department of Motor Vehicles (DMV) within 72 hours. This process is crucial as it ensures that all necessary details regarding the incident are accurately documented and reported to the state's Agency of Transportation. The form requires comprehensive details about the crash, including the time, location, the vehicles, and individuals involved. For crashes involving more than two vehicles, additional forms need to be completed to cover the details of all vehicles involved. Furthermore, the form serves as a notification for any changes to the driver's address when signed. It also includes a section dedicated to insurance information, emphasizing the importance of maintaining automobile liability insurance as per Vermont's laws. Failure or refusal to report such incidences or to provide satisfactory proof of insurance can lead to civil penalties, highlighting the state's stern stance on ensuring the safety and accountability of its motorists. Additionally, for crashes involving pedestrians or bicyclists, specific details about what they were doing at the time of the accident are also required.

Preview - Vermont Report Form

 

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

 

 

 

NUMBER OF OCCUPANTS

 

 

 

 

 

 

OR PEDESTRIAN OR BICYCLIST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OPERATOR NAME: LAST

 

 

 

 

 

FIRST

 

 

MIDDLE

OPERATOR NAME: LAST

 

 

 

 

 

 

 

FIRST

 

 

 

 

 

MIDDLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET OR BOX NO.

 

 

 

 

 

 

 

 

 

 

 

 

STREET OR BOX NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY OR TOWN

 

 

 

 

 

 

 

 

 

 

STATE

 

 

 

 

 

CITY OR TOWN

 

 

 

 

 

 

 

 

 

 

 

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP CODE

 

 

DATE OF BIRTH

 

 

GENDER

 

 

 

ZIP CODE

 

 

 

 

DATE OF BIRTH

 

 

 

 

 

GENDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OPERATOR’S LICENSE NO.

 

 

 

 

 

CLASS

 

 

 

STATE

 

 

OPERATOR’S LICENSE NO.

 

 

 

 

 

 

 

CLASS

 

 

 

 

 

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IDENTIFICATION NUMBER

 

 

 

 

PLATE NUMBER

 

 

PLATE STATE

 

 

 

IDENTIFICATION NUMBER

 

 

 

 

PLATE NUMBER

 

 

 

PLATE STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE YEAR

 

VEHICLE MAKE

 

 

VEHICLE MODEL

 

 

VEHICLE TYPE

 

VEHICLE YEAR

 

VEHICLE MAKE

 

 

 

 

VEHICLE MODEL

 

 

 

VEHICLE TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRAILER YEAR

 

TRAILER MAKE

 

 

 

TRAILER MODEL

 

TRAILER PLATE #

TRAILER YEAR

 

TRAILER MAKE

 

 

 

 

TRAILER MODEL

 

 

TRAILER PLATE #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMERCIAL

 

YES

 

NO

 

 

HAZARDOUS

 

YES

NO

COMMERCIAL

YES

 

NO

 

 

 

 

HAZARDOUS

 

 

 

 

YES

NO

VEHICLE

 

 

 

 

 

MATERIAL

 

 

VEHICLE

 

 

 

 

 

MATERIAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACTUAL COST

 

 

 

 

 

 

 

 

IF THE CRASH INVOLVED A PEDESTRIAN OR A BICYCLIST, COMPLETE

 

ACTUAL COST

 

 

 

 

 

OF VEHICLE #1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THE FOLLOWING INFORMATION

 

 

 

 

 

 

 

OF VEHICLE #2

 

 

 

 

 

REPAIRS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHAT WAS PEDESTRIAN OR BICYCLIST DOING

 

 

 

 

 

 

 

REPAIRS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROPERTY

 

 

 

 

 

 

 

 

 

WALKING WITH TRAFFIC

 

 

PLAYING IN ROAD

 

 

 

UNKNOWN

 

 

 

 

PROPERTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WALKING AGAINST TRAFFIC

 

 

GETTING ON/OFF VEHICLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DAMAGE OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DAMAGE OTHER

 

 

 

 

 

THAN VEHICLE

 

 

 

 

 

 

 

 

 

NOT IN ROADWAY

 

 

PUSHING VEHICLE

 

 

 

 

 

 

 

 

 

 

THAN VEHICLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPROXIMATE

 

 

 

 

 

 

 

 

 

CROSSING INTERSECTION

 

 

WORKING ON VEHICLE

 

 

 

 

 

 

 

 

 

 

APPROXIMATE

 

 

 

 

 

COST OF

 

 

 

 

 

 

 

 

 

CROSSING NOT AT AN

 

 

RIDING/PUSHING BIKE

 

 

 

 

 

 

 

 

 

 

COST OF

 

 

 

 

 

 

 

PROPERTY

 

 

 

 

 

 

 

 

 

INTERSECTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROPERTY

 

 

 

 

 

 

 

REPAIRS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REPAIRS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROPERTY OWNER’S NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROPERTY OWNER’S NAME

 

AND ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

WAS

 

 

 

 

 

 

 

POSITION

 

AGE

 

 

 

 

 

SEATBELT

 

OCCUPANT

(USE THE FIRST LINE FOR YOURSELF EVEN IF NOT

 

 

 

 

 

INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INJURED TAKEN TO

 

VEH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WITHIN

 

OF

 

 

 

GENDER

 

OR

 

 

THROWN

 

INJURED

 

 

 

(STATE “NONE” IF NOT INJURED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE

 

OCC.

 

 

 

 

 

HARNESS

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USED

 

 

VEHICLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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?

YES

NO

IF YES, GIVE NAME OF OFFICER:

 

 

 

 

 

 

 

 

 

OFFICER’S DEPARTMENT:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WERE YOU DRIVING A COMMERCIAL VEHICLE?

 

Yes

No

 

 

 

 

 

 

 

WAS THE VEHICLE TRANSPORTING HAZARDOUS MATERIALS?

Yes

No

 

 

 

 

 

 

 

IF YES, GIVE NAME OF MATERIAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF REPORT

OPERATOR SIGN HERE

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTINUE ON NEXT PAGE

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.

Yes

 

 

No

 

 

Name of your (Operator 1) Insurance Company (NOT AGENT):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Company Mailing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy Number:

 

 

 

 

 

 

 

 

 

 

Policy Period From:

 

 

 

to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Policy Holder:

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Operator at the time of the Crash:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Crash:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this motor vehicle covered by a Certificate of Self-Insurance?

 

Yes

 

No

If yes, certificate number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DO NOT DETACH FORM SR-21A

 

 

VERMONT DEPARTMENT OF MOTOR VEHICLES MONTPELIER VERMONT

 

DMV CRASH NUMBER

 

 

 

 

VERMONT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of insurance company with whom you are insured for liability or damage to others (For Operator #1):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Company mailing address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy Number:

 

 

 

 

 

 

 

 

 

 

Policy Period From:

 

 

 

to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Crash:

 

 

At or near (Town/City):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Make of your vehicle:

Year:

Type:

 

 

 

 

 

VIN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Operator:

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Policy Holder:

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

File Overview

Fact Detail
Requirement for Reporting The operator of every motor vehicle involved in a crash resulting in injury or death, or total property damage of $3,000.00 or more, must complete and submit this form within 72 hours.
Address Update Provision If the operator's address differs from the DMV records, signing this form will serve as a notice of address change, and the DMV records will be updated accordingly.
Insurance Information Requirement Under Vermont law, satisfactory proof of a standard provisions automobile liability insurance policy in full force at the time of the crash must be furnished. Failure to do so may result in the requirement to obtain Financial Responsibility Insurance for future operation of any motor vehicle.
Governing Law This form is governed by Vermont State law, requiring individuals involved in certain motor vehicle crashes to report the incident and furnish insurance details to demonstrate financial responsibility as per the stipulated requirements.

Vermont Report: Usage Guidelines

After a motor vehicle crash in Vermont, filling out the Vermont Report form becomes a critical step if the incident involves injury, death, or property damage of $3,000.00 or more. It's not just about documenting the occurrence; it's a legal requirement to submit this report within 72 hours to the Department of Motor Vehicles. Doing so ensures that all necessary steps are taken according to Vermont law, and helps facilitate any required follow-ups from the involved parties or the insurance company. Here's a guide on how to complete the form.

  1. Ensure you have a black or blue ink pen if you are filling out the form by hand or have access to a typewriter if you prefer that method.
  2. Start at the top of the form by entering the “Time of Crash,” including specifying A.M or P.M., then fill in the “Day of the Week” and the “Month/Day/Year of the Crash.”
  3. Provide the “Place of Crash,” including city or town, and the “Street/Route/Highway of Crash.”
  4. Under “Your Vehicle” and “Other Vehicle” sections, enter the number of occupants at the time of the crash, if applicable.
  5. Fill in the “Operator Name” section for both Operator #1 and Operator #2 (if present), including last, first, and middle names, along with the address, city, state, zip code, date of birth, and gender.
  6. Enter both operators' license numbers, class, and state under their respective sections.
  7. Fill in the identification number and plate number for both involved vehicles, including the state of the plate.
  8. Provide details about both vehicles, including “Vehicle Year,” “Make,” “Model,” and “Type.” Do the same for trailers if involved.
  9. Indicate whether the vehicles were commercial and if they were transporting hazardous materials by marking “Yes” or “No.”
  10. For each vehicle, specify the “Actual Cost of Repairs” if known. If a pedestrian or bicyclist was involved, complete the corresponding section.
  11. Fill in the “Property Damage” section, detailing the approximate cost of property repairs outside of vehicle damage.
  12. List the property owner's name and address in the “Property Owner’s Name and Address” section.
  13. Under “Occupant Data,” list all occupants’ names, addresses, nature, and extent of any injuries, and hospital information if applicable.
  14. Describe the crash in your own words in the provided space. If an additional sheet is necessary, make sure to attach it securely.
  15. Answer whether the crash was investigated by an officer, if you were driving a commercial vehicle, and if the vehicle was transporting hazardous materials.
  16. Sign and date the “Operator Sign Here” section to verify the accuracy of the information provided.
  17. Complete the insurance information request with utmost accuracy to ensure compliance with Vermont laws regarding liability insurance at the time of the crash.

After completing the form, double-check all provided details for accuracy before submission. Mail the form to the Department of Motor Vehicles at the address provided on the form. Timely and accurate reporting is essential, not only for legal compliance but also for ensuring the swift processing of any claims that may follow. Remember, this report may also need to be filed directly with your insurance company to avoid jeopardizing your coverage.

Your Questions, Answered

  1. Who must fill out the Vermont Report form following a motor vehicle crash?

    The operator of any motor vehicle involved in a crash resulting in either injury or death, or total property damage of $3,000.00 or more, must complete the Vermont Report form. This is required even if the vehicle was parked at the time of the incident. The completed form must be submitted within 72 hours to the Department of Motor Vehicles in Montpelier, Vermont.

  2. What happens if multiple vehicles are involved in the crash?

    If the crash involves more than two vehicles, additional forms must be filled out to ensure all vehicles involved are accounted for. Each vehicle involved in the incident requires a separate form to detail its specific information and the circumstances around it being part of the crash.

  3. What if my address has changed from what is on DMV records?

    If the address provided on the form is different from what is recorded with the DMV, signing the form will act as a notice of address change. Consequently, the DMV will update its records to reflect your new address as provided in the report.

  4. Is there a requirement to report crashes involving pedestrians or bicyclists?

    Yes, if the crash involved a pedestrian or a bicyclist, specific sections of the form must be completed to detail their involvement. Information regarding their actions at the time of the crash (e.g., walking with traffic, playing in the road) and the extent of any property damage or injuries should be included.

  5. What are the insurance requirements following a crash?

    Vermont law mandates that anyone involved in a crash resulting in bodily injury, death, or property damage totaling $3,000 or more must provide proof of an automobile liability insurance policy that was in effect at the time of the crash. Failure to do so may result in the requirement to obtain and furnish proof of Financial Responsibility Insurance for future operation of any motor vehicle.

  6. What should I do if I was driving a commercial vehicle or transporting hazardous materials at the time of the crash?

    The form includes sections to indicate whether the crash involved a commercial vehicle or the transportation of hazardous materials. If either is applicable, it is crucial to disclose this information by checking the appropriate box and, if hazardous materials were involved, listing the type of material being transported. This helps in assessing the potential for additional risks or damages resulting from the crash.

Common mistakes

When filling out the Vermont Report form for a motor vehicle crash, it's crucial to complete it accurately to avoid potential penalties or problems with insurance claims. Here, we highlight ten common mistakes to avoid when completing this form:

  1. Not reporting the crash within 72 hours can lead to penalties. It is a requirement to report any crash resulting in injury, death, or property damage of $3,000 or more within this timeframe.

  2. Failing to use ink or typewritten text for the submission. The form specifically requests that all information be completed fully in ink or typewritten to ensure legibility and permanence of the record.

  3. Omitting details about all vehicles involved in a crash with more than two vehicles. Each vehicle needs a separate form filled out to include comprehensive details of the event.

  4. Incorrectly reporting the number of occupants in each vehicle. This information is crucial for a thorough investigation and for insurance purposes.

  5. Forgetting to note the change of address if the current address is different from what is on the DMV records. Signing the form can act as a notice of address change.

  6. Not providing complete insurance information, including the policy number and period. This could be interpreted as not having auto liability insurance, risking a suspension of the license.

  7. Leaving the description of the crash and the involvement of a pedestrian or bicyclist blank or incomplete. Detailed accounts are essential for legal and insurance assessments.

  8. Misreporting or failing to report injuries of all occupants in the involved vehicles can affect insurance claims and legal responsibility.

  9. Not indicating whether the crash was investigated by an officer, which can be vital information for the DMV and insurance companies.

  10. Overlooking the requirement to also report the crash directly to the insurance company. Failure to do so may jeopardize automobile liability insurance.

Ensuring all sections of the Vermont Report form are completed thoroughly and accurately can significantly help in the prompt and fair resolution of any claims or legal matters stemming from a vehicle crash.

Documents used along the form

When individuals are involved in a motor vehicle crash in Vermont, the Vermont Report Form serves as a crucial document for legally reporting the incident. Besides this required form, several other forms and documents are often used in conjunction to ensure comprehensive coverage of the event, legal compliance, and facilitation of any resulting claims or legal actions. These additional documents support the initial report, offer detailed evidence, comply with insurance requirements, or serve legal notice as needed.

  • Insurance Information Exchange Form (SR-22): This form is used when one needs to provide proof of auto insurance to the state. It's particularly used after certain violations or to reinstate a suspended license, certifying that the vehicle owner has the minimum liability coverage required by state law.
  • Medical Authorization Release Form: After an accident, this form allows the release of medical records to insurance companies or attorneys. It's used to document injuries related to the accident and can be crucial for personal injury claims.
  • Property Damage Release Form: This document is used to settle claims related to property damage only. Signing it releases the at-fault party from further claims after the compensation is paid.
  • Vehicle Release Form: In crashes resulting in the impounding of a vehicle, this form is necessary to retrieve the vehicle from a tow lot or impound. It typically requires proof of ownership and payment of any impound fees.
  • Witness Statement Form: This form is used to record the account of eyewitnesses to the crash. Witness statements can provide valuable, objective perspectives that might support claims or establish facts in legal proceedings.
  • Photographic Evidence: While not a form, photographic evidence of the crash scene, vehicle damage, and injuries is often submitted alongside the Vermont Report Form to provide visual documentation of the incident and support claims or legal action.

Together, these forms and documents comprise a comprehensive set of paperwork that can be crucial for legal, insurance, and personal record purposes following a vehicle crash. Each plays a specific role in the broader context of post-accident procedures, from verifying insurance compliance to detailing personal injuries and property damage. Understanding the purpose and proper use of each can significantly affect the outcome of insurance claims, legal actions, and the recovery process for all involved parties.

Similar forms

The Vermont Report form is closely related to the California Traffic Accident Report form. Both serve the primary purpose of documenting traffic accidents for state departments of motor vehicles (DMVs). They require detailed information on the crash, including the time, date, location, and vehicles involved. Specifically, both forms ask for information about the drivers' insurance coverage, a description of event, and personal details of the drivers and passengers. This comprehensive approach ensures accurate records for legal, insurance, and statistical purposes.

Similar to the Uniform Accident Report forms used by several states, the Vermont Report form collects standardized data on motor vehicle crashes. These Uniform Accident Reports are designed to facilitate data collection on a national scale, contributing to broader safety studies and the development of strategies to prevent crashes. Both types of documents include sections for vehicle and driver identification, crash circumstances, and detailed diagrams or descriptions of the crash scene. The design of these forms allows for the aggregation and comparison of accident data across different jurisdictions.

The Driver’s Crash Report form in Texas shares several similarities with the Vermont version, especially in the way it mandates drivers involved in certain types of accidents to self-report incidents. Both forms are necessary when law enforcement does not respond to the scene, and they require the driver to detail the incident, including damages and injuries, within a specific timeframe. The emphasis on self-reporting underscores the responsibility of drivers to document and inform the state DMV about crashes that meet certain criteria.

The Police Crash Report forms used in New York are akin to the Vermont Report form in their detail and purpose. They are filled out by officers who respond to accident scenes, and like the Vermont form, they capture a wealth of information about crashes. These documents include diagrams of the incident, descriptions of the accident, details about property damage, and any injuries sustained. While the audience filling out the form might differ, the core information collected remains aimed at documenting the incident thoroughly for legal and insurance considerations.

The SR-1 Form used by the California DMV for reporting collisions is another document similar to Vermont's crash report. Like Vermont's form, it is geared towards both meeting legal reporting requirements and facilitating insurance claims. Drivers involved in accidents that result in injury, death, or significant property damage must complete the form. The detailed reporting aids in the accurate assessment of incidents, serving as crucial documentation for all parties involved in the aftermath of a crash.

The Accident Report Form used in the UK, while not American, shares similarities with the Vermont Report form in its comprehensive nature and its role in the documentation and analysis of vehicle accidents. Both forms are instrumental in compiling data that can influence road safety policies and insurance claims processes. The detailed account of the accident provided by these forms, including the environmental and road conditions, offers insights into common factors contributing to accidents, thereby informing efforts to improve road safety.

The Oregon Traffic Accident and Insurance Report is closely aligned with the Vermont Report form in terms of its use for documenting vehicular accidents that surpass a specific damage threshold. In both states, filling out and submitting these reports to the respective DMV is mandatory under these circumstances. These forms collect detailed information about the incident, drivers, passengers, and vehicles involved, which is critical for insurance claims and legal purposes. This reporting process ensures that there is an official record of the accident, which can be referenced in future proceedings related to the incident.

Dos and Don'ts

When filling out the Vermont Report form for a motor vehicle crash, it's important to pay careful attention to the details required. To ensure accuracy and completeness, here are some dos and don'ts:

  • Do ensure all information is completed in full. Incomplete forms may lead to processing delays or potential fines.
  • Do use ink or type when filling out the form, as this ensures the information remains legible and permanent for official records.
  • Do report the crash within 72 hours if it results in injury, death, or total property damage of $3,000.00 or more. Timeliness is crucial for legal and insurance purposes.
  • Do include detailed information about all vehicles and persons involved. For crashes involving more than two vehicles, use additional forms as needed.
  • Do provide accurate insurance information. This is essential for verifying coverage and fulfilling legal requirements.
  • Don't leave any sections blank. If a section does not apply, indicate with "N/A" (not applicable) to show that you considered every part of the form.
  • Don't forget to sign the form. An unsigned form is not valid and will not be processed.
  • Don't neglect to report the crash directly to your insurance company, in addition to filling out this form. Failing to do so could jeopardize your coverage.
  • Don't underestimate the importance of including a detailed description of the crash in your own words. This narrative can be crucial for insurance and legal assessments.

Remember, accurately and promptly completing the Vermont Report form is not only a legal requirement but also a crucial step in the insurance claim process. Ensuring all details are correctly reported can help facilitate a smoother recovery from the incident.

Misconceptions

There are several common misunderstandings about the Vermont Report form that need to be cleared up. Let's address seven key misconceptions to ensure everyone is correctly informed about how to use this form following a motor vehicle crash.

  • Only at-fault drivers need to fill out the form. Regardless of who is at fault, the operator of every motor vehicle involved in a crash resulting in injury, death, or total property damage of $3,000.00 or more is required to report the incident using this form within 72 hours.

  • The form is optional for minor accidents. Even if the damage seems minor, if the total property damage meets or exceeds $3,000.00 or if there's any injury or death, completing this form is mandatory, not optional.

  • Your license won't be affected if you don't fill it out. Failure or refusal to report an accident as required can lead to a civil penalty, and it is implied that non-compliance could result in a suspension of your driving privileges in Vermont.

  • Digital submissions are acceptable. The form specifies that all information must be completed in ink or typewritten, implying that a hard copy submission is required, and not just a digital form or email.

  • If you're not a Vermont resident, you don't need to file this report. The law applies to everyone involved in a relevant crash within Vermont's jurisdiction, regardless of their state residency.

  • Insurance information is optional. Vermont law requires satisfactory proof of a standard provisions automobile liability insurance policy in force at the time of the crash. Failure to provide this information could lead to the assumption that you do not have automobile liability insurance, further affecting your driving privileges.

  • You only need to fill out part of the form if the accident was minor. The form requires that all requested information must be completed in full. Selectively filling out the form could lead to incomplete reporting and potential penalties.

Understanding these nuances ensures accurate and complete reporting, aiding in the smooth handling of post-accident procedures and insurance claims.

Key takeaways

When it comes to the Vermont Report of a Motor Vehicle Crash, understanding the key requirements is crucial for timely and accurate completion. Below are ten essential takeaways to guide you through the process:

  • The report must be filled out fully in ink or typewritten, ensuring no section is left incomplete.
  • This form is required for any vehicle crash that results in injury or death, or where the total property damage exceeds $3,000.00, highlighting the need for careful evaluation of the crash's impact.
  • A report must be submitted within 72 hours post-accident, underscoring the importance of acting swiftly following a crash.
  • Failure to report a crash as mandated can lead to civil penalties, emphasizing the legal ramifications of non-completion.
  • If a crash involves more than two vehicles, additional forms must be used to account for all vehicles involved, ensuring comprehensive reporting.
  • The form also functions as a notice of address change if the operator’s current address differs from the one on DMV records. This dual purpose simplifies the process of keeping records up to date.
  • Details about both vehicles involved, including the year, make, model, and type, must be accurately reported, providing a clear picture of the incident scope.
  • If the crash involved a pedestrian or a bicyclist, specific sections regarding their actions at the time of the crash need completion, highlighting the need for detail in scenarios involving vulnerable road users.
  • All occupants' data in all vehicles involved must be documented, including their names, addresses, and the extent of any injuries, ensuring all affected parties are accounted for.
  • The form requires information on insurance coverage at the time of the crash, underlining the legal requirement for motorists to furnish proof of liability insurance in the event of an accident.

Completing the Vermont Report of a Motor Vehicle Crash form accurately and promptly is not just about compliance with statutory requirements; it's also about ensuring the well-being of all involved parties and facilitating the accurate evaluation of incidents on Vermont's roads.

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