MISSOURI DEPARTMENT OF REVENUE
DRIVER LICENSE BUREAUPrint

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MOTOR VEHICLE ACCIDENT REPORT(REV. 6-2006)

GENERAL INFORMATION(The following information is based on Chapter 303 RSMo.)

Q: When should I file this accident report?
A: File this report if all of the following are true:✓ The accident happened in Missouri.
✓ The accident happened within the last 12 months.
✓ Someone involved in the accident did not have insurance.
Q: Can I submit the police report instead of completing this accident report?
A: No. The law requires you to report the accident using the attached form.
Q: What happens after this report is filed?
A: An uninsured person’s driver license and/or plates can be taken away for one or both of the following reasons:•He/she does not show us proof of insurance for the accident.

•He/she is found to be at fault for the accident and does not send security compliance (see below) to us.

Q: What is security?
A: Security is the amount of money that we find the uninsured person(s) is responsible for based on his/her percentageof fault for the accident and the amount of damages on file. The most common forms of security compliance are:•Installment Agreement: A notarized payment plan agreed to by you and the uninsured person(s).

•Release: A sworn statement from you releasing the uninsured person(s) from responsibility for the accident.

•Cash Deposit: A deposit of cash sent to us from the uninsured person(s) for the full amount of security.
We must return the deposit to the uninsured person(s) after one year from the accident date unless the parties
agree to a settlement or a lawsuit is filed against the person(s) for whom the deposit was made.
The deposit can only be applied toward a judgment against the person(s) for whom the deposit was made.
We will send you instructions on how to obtain the deposit, if one is made.

•One-Year Suspension: The uninsured person(s) can choose to remain suspended for one year instead of submitting security compliance. The suspension can be extended if a lawsuit is filed in court within one year of the accident date and a copy of the petition is sent to us.

Q: Will the state file the lawsuit?
A: No. You must file the lawsuit in court if you wish to do so.
Q: Will you let me know when the uninsured person’s driver license and/or plates will be suspended?
A: Yes, if you contact us. Please allow up to 90 days for us to process your accident report and determine a percentageof fault for the accident.
Q: How can I contact you?
A: You may contact us at Driver License Bureau, P.O. Box 200, Jefferson City, Missouri 65105-0200,
dlbmail@dor.mo.gov or (573) 751-7195.
Q: Is the accident report form available on the Internet?
A: Yes. The Motor Vehicle Accident Report Form is now available in fillable PDF format.
www.dor.mo.gov/mvdl/ for more information.

MO 860-0427 (6-2006)

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DOR-1140 (6-2006)

MISSOURI DEPARTMENT OF REVENUE
DRIVER LICENSE BUREAU

MOTOR VEHICLE ACCIDENT REPORTFORM

1140(REV. 6-2006)

INSTRUCTIONS FOR COMPLETING THIS FORM.

PART 1:

Fill in all blanks with the information requested.

PART 2:Fill in your vehicle driver and owner information. If the vehicle was parked, write “parked” in the vehicle driverbox and fill in the owner information. If you were not a vehicle driver or owner, mark the correct box under “YourInvolvement” and fill in the information in the spaces provided.
Fill in your liability insurance information and mark the correct box. (This is only required if you are the vehicle
driver and/or owner.)

PART 3:Sign your name and mark the correct box.

PART 4:Fill in the driver, owner, and vehicle information for all other involved parties.

PART 5:Draw a diagram of the accident using the symbols and instructions on the form.
Explain how the accident happened, in your own words.

Attach a denial letter from the uninsured person’s insurance company, if you have one. The letter should state the reason
why coverage was denied for the accident. It must be on the company’s stationery and signed by the person who reviewed
the claim.
PROPERTY DAMAGE AND/OR BODILY INJURY DOCUMENTS
1. In order to determine a percentage of fault and require security for your loss, both of the following statements must
apply.
A. There was more than $500 in damage to one or more person’s property, or there was bodily injury or death.
B. It has been less than nine months since the accident happened.
Reason: A notice must be sent to the uninsured person within one year of the accident date. We need 90 days
to process the accident report and determine a percentage of fault for the accident.
2. If statements 1.A and 1.B do apply, attach any of the following documents that pertain to this accident.
•An estimate of repair cost for the vehicle or other property. (It must be readable, itemized, and contain the accidentdate or estimate date. It must also contain the name and address of the repair shop or insurance company);•A doctor’s report and/or medical bills. (The type of injury must be explained in detail and the service date must beincluded. It must also contain the name and address of the healthcare provider); and/or•

A copy of a death certificate or police report showing there was a death.

3. If statements 1.A. and/or 1.B. do not apply, the uninsured person’s driver license and/or plates can be taken away for
not having insurance at the time of the accident. The accident report must be mailed to us within one year of theaccident date.
MAIL THE COMPLETED ACCIDENT REPORT FORM AND ANY ATTACHMENTS TO THE DRIVER LICENSE BUREAU,P.O. BOX 200, JEFFERSON CITY, MISSOURI 65105-0200, OR FAX TO (573) 526-7365.

MO 860-0427 (6-2006)

DOR-1140 (6-2006)

PrintDOR USE ONLYFORMMISSOURI DEPARTMENT OF REVENUE
DRIVER LICENSE BUREAU

1140

MOTOR VEHICLE ACCIDENT REPORTReset

NAIC NUMBER

ORI NUMBER

CASE NUMBER(REV. 6-2006)

PART 1 — ACCIDENT INFORMATION STOP➞ ONLY REPORT ACCIDENTS OCCURRING IN MISSOURIACCIDENT DATETIMEACCIDENT LOCATION - STREET NAME OR HIGHWAY NUMBERNUMBER OF VEHICLES INVOLVEDCOUNTY

A.M.
P.M.

STATEWAS A POLICE REPORT MADE?

YESIF YES, WHAT POLICE AGENCYNOPART 2 — YOUR INFORMATIONVEHICLE DRIVER

VEHICLE OWNER

DRIVER’S NAMESEXSTREET ADDRESSCITY, STATEZIP CODEDATE OF BIRTH

DRIVER LICENSE NUMBER

STATEOWNER’S NAMEDATE OF BIRTHSTREET ADDRESSDRIVER LICENSE NUMBER

CITY, STATEVEHICLE MAKE/YEARSEXZIP CODE

MODEL

LICENSE PLATE NUMBER

STATE

INVOLVEMENT (IF OTHER THAN VEHICLE DRIVER/OWNER)NAMEDATE OF BIRTHSEXSTREET ADDRESSDRIVER LICENSE NUMBERPASSENGERPEDESTRIANPROPERTY OWNER (OTHER THAN VEHICLE)TYPE OF PROPERTY ______________________ CITY, STATEOTHER __________________________________ZIP CODEYOUR LIABILITY INSURANCE INFORMATIONWAS YOUR VEHICLE COVERED BY LIABILITY INSURANCE AT THE TIME OF THE ACCIDENT?
YESNOSTOP➞ YOU MUST MARK A BOX!

IMPORTANT! IF YOU MARK YES, YOU MUST PROVIDE YOUR INSURANCE COMPANY NAME AND POLICY NUMBER BELOW.
FAILURE TO PROVIDE THIS INFORMATION MAY RESULT IN SUSPENSION ACTION.

INSURANCE COMPANY NAME (NOT AGENCY OR BROKERAGE)

PART 3 — SIGNATURE STOP

INSURANCE POLICY/CLAIM NUMBER➞ YOU MUST SIGN THE REPORT OR IT WILL BE RETURNED TO YOUI STATE THAT THE INFORMATION ON BOTH SIDES OF THIS REPORT IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
SIGNATUREClick here for signature information.

I AM:DRIVEROWNERPROPERTY OWNERINSURANCE COMPANY REPRESENTATIVECOMPLETE REVERSE SIDE
MO 860-0427 (6-2006)➞ATTORNEYPASSENGERPEDESTRIANCORPORATE OFFICER

DOR-1140 (6-2006)

PART 4 — OTHER INVOLVED PARTIES (USE ADDITIONAL FORMS IF NECESSARY)OTHER VEHICLE — DRIVER INFORMATIONOTHER VEHICLE — OWNER INFORMATION

DRIVER’S NAMESEXSTREET ADDRESSCITY, STATEDATE OF BIRTH

DRIVER LICENSE NUMBER

VEHICLE MAKE/YEAR

MODEL

LICENSE PLATE NUMBERSTATE

OWNER’S NAMEDATE OF BIRTHSTREET ADDRESSDRIVER LICENSE NUMBERCITY, STATESTATE

VEHICLE MAKE/YEARSEXZIP CODEMODEL

LICENSE PLATE NUMBERSTATEOTHER VEHICLE — OWNER INFORMATION

DRIVER’S NAMESEXSTREET ADDRESSDRIVER LICENSE NUMBERZIP CODEZIP CODEOTHER VEHICLE — DRIVER INFORMATIONDATE OF BIRTHSEXOTHER VEHICLE — OWNER INFORMATIONSTREET ADDRESSCITY, STATEDRIVER LICENSE NUMBERSTATESEXDRIVER LICENSE NUMBER

STREET ADDRESSCITY, STATEDRIVER’S NAMEDATE OF BIRTHDATE OF BIRTH

ZIP CODEOTHER VEHICLE — DRIVER INFORMATIONCITY, STATEOWNER’S NAMEOWNER’S NAMEDATE OF BIRTHSTREET ADDRESSDRIVER LICENSE NUMBER

ZIP CODE

CITY, STATESTATE

VEHICLE MAKE/YEARSEXZIP CODEMODEL

LICENSE PLATE NUMBERSTATEPART 5 — DIAGRAM DESCRIPTION OF ACCIDENTNORTHINSTRUCTIONS➜DRAW PICTURE OF ROADWAY AT PLACE OF
ACCIDENT. NUMBER EACH VEHICLE AND SHOWDIRECTION OF TRAVEL BY ARROW.

➞12➞EXAMPLESYMBOLS
1. VEHICLE

4. RAILROAD

2. MOTORCYCLE

5. UTILITY POLE

3. PEDESTRIANDESCRIBE WHAT HAPPENED (REFER TO VEHICLES BY NUMBER, AND BY NAME OF DRIVER(S))

MAIL TO: MISSOURI DEPARTMENT OF REVENUE, DRIVER LICENSE BUREAU, P.O. BOX 200, JEFFERSON CITY, MISSOURI 65105-0200,
OR FAX TO: (573) 526-7365. PHONE: (573) 751-7195. E-MAIL: dlbmail@dor.mo.gov
MO 860-0427 (6-2006)

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