Fillable Form VA-004

What is Form VA-004?

Form VA-004, Report of a Motor Vehicle Crash, is a state-level form in the state of Vermont. The Vermont Motor Vehicle Crash Report Form is used by a driver in Vermont to report a vehicle crash, whether other vehicles or another vehicle is involved or not. It is issued by the Vermont Department of Motor Vehicles (DMV).

When using Form VA-004, you must take note that the word “crash” refers only to situations, incidents, or events when a motor vehicle comes into physical contact with another motor vehicle, a non-living thing or object, or a person.

Where to get Form VA-004?

The Vermont Department of Motor Vehicles provides a blank copy of Form VA-004. You may also visit the official Vermont DMV website to download and print a copy that you can fill out manually. Alternatively and for your convenience, you may electronically fill out Form VA-004 on PDFQuick.

How to fill out Form VA-004?

Form VA-004 is a three-page form that requires your personal information, crash-related details, and the information of the other vehicle, pedestrian, or bicyclist involved.

Answer all the fields accurately and truthfully to avoid any problems with your report. Moreover, you must not deliberately provide any false information as doing so is unlawful and may result in penalties and imprisonment.

According to the Vermont Report of a Motor Vehicle Crash, the operator of every motor vehicle involved in a crash that resulted in injury or death of an individual or total property damage worth $3,000 or more — including all vehicles involved and physical property damage — should make a report using Form VA-004 within 72 hours to the Vermont Department of Motor Vehicles. If you are the one involved, you must report even when the vehicle was parked. Failure or refusal to report a crash is punishable by a civil penalty.

Answer all the applicable items.

Time of Crash

Enter the time the crash happened. Then, mark the appropriate box to determine whether the crash happened in the A.M. or P.M.

Day of Week

Enter the day of the week the crash happened.

Month Day Year of Crash

Enter the date the crash happened in the following format: MM/DD/YYYY.

Place of Crash (City or Town)

Enter the name of the city or town where the crash happened.

Street/Route/Highway of Crash

Enter the name of the street, route, or highway where the crash happened.

Your Vehicle

Number of Occupants

Enter the number of people inside the vehicle when the crash happened.

Operator Name: Last, First, Middle

Enter your name in the following order: Last Name, First Name, Middle Name.

Street or Box No.

Enter your street or box number, whichever is applicable.

City or Town

Enter the name of the city or town where you live.

State

Enter the name of the state where you live.

ZIP

Enter your ZIP code.

Date of Birth

Enter your date of birth.

Gender

Enter your gender.

Operator's License No.

Enter your license number.

Class

Enter the class of your license.

State

Enter the name of the state where your license was issued.

Identification Number

Enter your state identification number.

Plate Number

Enter your vehicle’s plate number.

Plate State

Enter the name of the state where your plate was issued.

Vehicle Year

Enter the year your vehicle was made.

Vehicle Make

Enter the make of your vehicle.

Vehicle Model

Enter the model of your vehicle.

Vehicle Type

Enter the type of your vehicle.

Trailer Year

Enter the year your trailer was made.

Trailer Make

Enter the make of your vehicle.

Trailer Model

Enter the model of your vehicle.

Trailer Plate #

Enter the plate number of your trailer.

Commercial Vehicle

Mark “YES” if your vehicle is a commercial vehicle; otherwise, mark “No.”

Hazardous Material

Mark ‘YES” if your vehicle contains any hazardous material; otherwise, mark “No.”

Actual Cost of Vehicle #1 Repairing

Enter the actual cost of repairing your vehicle.

Property Damage Other Than Vehicle

Enter the property damage aside from your vehicle, if applicable.

Approximate Cost of Property Repairs

Enter the approximate cost of repairing any damaged property.

Property Owner’s Name and Address

Enter the name and address of the person whose property was damaged.

Other Vehicle or Pedestrian or Bicyclist

Number of Occupants

Enter the number of people inside the other vehicle when the crash happened.

Operator Name: Last, First, Middle

Enter the other operator’s name in the following order: Last Name, First Name, Middle Name.

Street or Box No.

Enter the other operator’s street or box number, whichever is applicable.

City or Town

Enter the name of the city or town where the other operator lives.

State

Enter the name of the state where the other operator lives.

ZIP

Enter the other operator’s ZIP code.

Date of Birth

Enter the other operator’s date of birth.

Gender

Enter the other operator’s gender.

Operator's License No.

Enter the other operator’s license number.

Class

Enter the class of the other operator’s license.

State

Enter the name of the state where the other operator’s license was issued.

Identification Number

Enter the other operator’s state identification number.

Plate Number

Enter the other operator’s vehicle’s plate number.

Plate State

Enter the name of the state where the other operator’s plate was issued.

Vehicle Year

Enter the year the other operator’s vehicle was made.

Vehicle Make

Enter the make of the other operator’s vehicle.

Vehicle Model

Enter the model of the other operator’s vehicle.

Vehicle Type

Enter the type of the other operator’s vehicle.

Trailer Year

Enter the year the other operator’s trailer was made.

Trailer Make

Enter the make of the other operator’s vehicle.

Trailer Model

Enter the model of the other operator’s vehicle.

Trailer Plate #

Enter the plate number of the other operator’s trailer.

Commercial Vehicle

Mark “YES” if the other operator’s vehicle is a commercial vehicle; otherwise, mark “No.”

Hazardous Material

Mark ‘YES” if the other operator’s vehicle contains any hazardous material; otherwise, mark “No.”

Actual Cost of Vehicle #2 Repairing

Enter the actual cost of repairing the other operator’s vehicle.

Property Damage Other Than Vehicle

Enter the property damage aside from the other operator’s vehicle, if applicable.

Approximate Cost of Property Repairs

Enter the approximate cost of repairing any damaged property.

Property Owner’s Name and Address

Enter the name and address of the person whose property was damaged.

If the crash involved a pedestrian or a bicyclist, complete the following information:

What was the pedestrian or bicyclist doing

Mark the appropriate box to determine what the pedestrian or bicyclist was doing when the crash happened. You may select:

• Walking with traffic


• Walking against traffic


• Not in roadway


• Crossing intersection


• Crossing not at an intersection


• Playing in road


• Getting on/off vehicle


• Pushing vehicle


• Working on vehicle


• Riding/pushing bike


• Unknown

Other

Describe the situation when not in the options.

Describe Injury

Describe the injury the pedestrian or bicyclist has sustained.

Occupant Data

Provide all of the following information about you and all the occupants in all vehicles:

• Occupant’s Name and Address


• Nature and Extent of Injury


• Name of Hospital Injured Taken To


• Veh (Vehicle) No.


• Position Within Vehicle


• Age of Occ. (Occupant)


• Gender


• Was Seatbelt or Harness Used


• Was Occupant Thrown From Vehicle

Describe in your own words what happened

Use the box to describe the crash.

Mark “YES” if the crash was investigated by an officer; otherwise, mark “No.” If you marked “YES,” enter the name of the officer.

Officer’s Department

Enter the department of the officer.

Mark “YES” if you were driving a commercial vehicle; otherwise, mark “No.”

Mark “YES” if the vehicle was transporting hazardous materials; otherwise, mark “No.” If you marked “YES,” enter the name of the material.

Operator Sign Here

Affix your signature.

Date of Report

Enter the date of your report.

Operator #1 should complete both sections on page 3 of Form VA-004.

Name of Insurance Company

Enter the name of your insurance company, not the name of your agent.

Insurance Company Mailing Address

Enter the mailing address of your insurance company.

Policy Number

Enter your insurance policy number.

Policy Period From

Enter the start date when your insurance became valid.

To

Enter until when your insurance is valid.

Name of Policy Holder

Enter the name of the policy holder.

Address

Enter the address of the policy holder.

Name of Operator at the time of the Crash

Enter the name of the operator at the time the crash happened.

Date of Crash

Enter the date the crash happened.

Mark “YES” if the motor vehicle is covered by a Certificate of Self-Insurance; otherwise, mark “No.” If you marked “YES,” enter the certificate number.

DMV Crash Number

Enter the DMV crash number.

Name of insurance company with whom you are insured for liability or damage to others

Enter the name of the insurance company that will handle your liability or damage to others.

Insurance Company Mailing Address

Enter the mailing address of the insurance company.

Policy Number

Enter the policy number of your insurance.

Policy Period From

Enter the start date when your insurance became valid.

To

Enter until when your insurance is valid.

Date of Crash

Enter the date the crash happened.

At or near (Town/City)

Enter the name of the town or city where the crash happened or any town or city nearest to the crash.

Make of your vehicle

Enter the make of your vehicle involved in the crash.

Year

Enter the year of your vehicle.

Type

Enter the type of your vehicle.

VIN

Enter your Vehicle Identification Number.

Operator

Enter your name.

Address

Enter your address.

Name of Policy Holder

Enter the name of the policy holder.

Signature of Operator

Affix your signature.