The Vermont Report Form is a document required by the Department of Motor Vehicles for reporting motor vehicle crashes involving injury, death, or significant property damage. This form must be completed by the operator of each vehicle involved in the incident and submitted within 72 hours. Timely and accurate reporting is crucial to avoid potential penalties, so ensure all necessary information is provided.
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The Vermont Report form is a crucial document for anyone involved in a motor vehicle crash within the state. This form must be completed when a crash results in injury, death, or property damage exceeding $3,000. It is essential that all operators of vehicles involved in the incident fill out the form accurately and submit it to the Department of Motor Vehicles within 72 hours. The report captures vital information, including the details of all vehicles and occupants involved, the time and location of the crash, and any injuries sustained. If there are more than two vehicles involved, additional forms should be completed to ensure comprehensive reporting. The form also requires insurance information, which is mandatory under Vermont law. Failure to report or provide the necessary insurance details can lead to civil penalties and may affect the operator's driving privileges. Notably, if the operator's address differs from DMV records, submitting the form will also serve as a notice of address change. Completing this form accurately is not just a legal obligation; it plays a critical role in ensuring that all parties receive the necessary support and accountability following a crash.
Addendum Real Estate - The addendum is effective as of the indicated date.
The importance of the Employment Verification process cannot be overstated in ensuring a transparent hiring environment. For more information on how to navigate this process effectively, visit our page on understanding Employment Verification requirements.
Vermont Resale Certificate - Certificate retention for sellers is essential for tax compliance purposes.
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
The Vermont Report form shares similarities with the Accident Report form often used in other states. Like the Vermont form, the Accident Report requires individuals involved in a vehicle crash to provide detailed information about the incident. This includes the date, time, and location of the crash, as well as the names and addresses of all parties involved. Additionally, both forms necessitate a description of the vehicles and any injuries sustained, ensuring that all relevant details are documented for future reference. The goal is to create a comprehensive record that can assist in any legal or insurance matters that may arise following the accident.
In situations where managing one’s affairs becomes challenging, having a reliable Power of Attorney form is essential, as it allows individuals to ensure their decisions are respected. This form not only empowers agents to act on behalf of the principal but also encompasses various authorities, providing flexibility and assurance. For those in California, you can find the necessary documentation through resources like All California Forms, ensuring that your legal needs are met effectively and efficiently.
Another document that is similar to the Vermont Report form is the Police Report. This report is typically generated by law enforcement officers who respond to the scene of a crash. While the Vermont form is filled out by the individuals involved, the Police Report provides an official account of the incident from the perspective of the responding officers. It includes details such as witness statements, officer observations, and any citations issued. Both documents aim to capture the facts of the crash, but the Police Report carries the weight of an official investigation, which can be crucial in determining liability and resolving disputes.
The Insurance Claim Form is yet another document that bears resemblance to the Vermont Report form. This form is submitted to an insurance company to initiate a claim for damages resulting from a vehicle crash. Like the Vermont Report, it requires detailed information about the accident, including the parties involved, the extent of damages, and any injuries. Both forms serve the purpose of providing necessary documentation to facilitate the claims process. However, the Insurance Claim Form is specifically designed to communicate with insurance providers, while the Vermont Report is a legal requirement for state records.
Lastly, the Driver's Accident Statement is comparable to the Vermont Report form. This document is often used in conjunction with insurance claims and provides a narrative from the driver’s perspective about what happened during the crash. Similar to the Vermont form, it requires details about the accident, including time, location, and circumstances. Both documents emphasize the importance of accurate and thorough reporting to ensure that all parties have a clear understanding of the events leading up to the crash. The Driver's Accident Statement, however, is usually less formal and may not be submitted to a government agency, focusing instead on the needs of the insurance company.
This is not true. The form must be completed for any crash that results in total property damage of $3,000 or more, regardless of whether anyone was injured. This requirement ensures that all significant incidents are documented.
In reality, the law mandates that reports must be submitted within 72 hours of the crash. Delaying this report can lead to penalties, so it’s crucial to act promptly.
While the operator must complete the form, it is also essential to provide information about all occupants involved in the crash. This ensures that everyone’s details are accurately recorded.
This is incorrect. Even if your vehicle was parked, you must report the crash if it meets the criteria for property damage or injury. Reporting is necessary to maintain accurate records.
On the contrary, providing insurance information is a legal requirement. Failure to furnish this information can result in a suspension of your driving privileges.
This is a common misunderstanding. It is vital to report the crash directly to your insurance company as well. Not doing so may jeopardize your coverage and could lead to complications later.