"Pedicab Accident Report" - New York City

Pedicab Accident Report is a legal document that was released by the New York City Department of Consumer Affairs - a government authority operating within New York City.

Form Details:

  • Released on September 1, 2015;
  • The latest edition currently provided by the New York City Department of Consumer Affairs;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New York City Department of Consumer Affairs.

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Download "Pedicab Accident Report" - New York City

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42 Broadway | New York, NY 10004 | nyc.gov/consumers
PEDICAB ACCIDENT REPORT
PEDICAB DRIVER:
If you are involved in an accident during which someone is killed or is injured and requires medical treatment, you must immediately:
1)
Call 911 to report the accident. AND
2)
Notify the pedicab business owner. AND
3)
Provide your name, address, and information about liability insurance coverage to any person sustaining physical injury or property
damage in the accident.
PEDICAB BUSINESS OWNER:
As soon as you are notified that one of your pedicab drivers has been involved in an accident during which someone was killed or was injured
and requires medical treatment, you must immediately:
1)
Call (212) 487-8768 or e-mail
accidentreports@dca.nyc.gov
to notify the Department of Consumer Affairs (DCA) about the time and
location of the accident and any deaths or injuries requiring medical treatment.
IMPORTANT: Within 24 hours of any accident, BOTH THE PEDICAB DRIVER AND PEDICAB BUSINESS OWNER must jointly sign
and submit this form to DCA by e-mail to accidentreports@dca.nyc.gov. Failure to do so may result in fines and/or license suspension or
revocation.
PEDICAB BUSINESS LICENSEE INFORMATION
Name of Pedicab Business (Licensee):
Address:
DCA Pedicab Business License Number:
Owner, Principal, or Officer Name:
Telephone Number:
Pedicab Registration Plate Number:
Pedicab Identifying Number (PID):
Manufacturer:
PEDICAB DRIVER LICENSEE INFORMATION
Name of Pedicab Driver (Licensee):
DCA Pedicab Driver License Number:
Telephone Number:
ACCIDENT INFORMATION
Date of Accident:
Approximate Time of Accident:
Place Where Accident Occurred:
1. Was anyone killed in the accident?
Yes
No
If Yes, print the name, telephone number, and address of the person(s) below, if known:
2. Did anyone sustain an injury requiring medical attention?
Yes
No
If Yes, print the name, telephone number, and address of the injured person(s) below and describe the nature of the injuries:
3. Was any property damaged, including the pedicab?
Yes
No
If Yes, print the name of the property owner, telephone number, and address below, with a brief description of the damaged property:
42 Broadway | New York, NY 10004 | nyc.gov/consumers
PEDICAB ACCIDENT REPORT
PEDICAB DRIVER:
If you are involved in an accident during which someone is killed or is injured and requires medical treatment, you must immediately:
1)
Call 911 to report the accident. AND
2)
Notify the pedicab business owner. AND
3)
Provide your name, address, and information about liability insurance coverage to any person sustaining physical injury or property
damage in the accident.
PEDICAB BUSINESS OWNER:
As soon as you are notified that one of your pedicab drivers has been involved in an accident during which someone was killed or was injured
and requires medical treatment, you must immediately:
1)
Call (212) 487-8768 or e-mail
accidentreports@dca.nyc.gov
to notify the Department of Consumer Affairs (DCA) about the time and
location of the accident and any deaths or injuries requiring medical treatment.
IMPORTANT: Within 24 hours of any accident, BOTH THE PEDICAB DRIVER AND PEDICAB BUSINESS OWNER must jointly sign
and submit this form to DCA by e-mail to accidentreports@dca.nyc.gov. Failure to do so may result in fines and/or license suspension or
revocation.
PEDICAB BUSINESS LICENSEE INFORMATION
Name of Pedicab Business (Licensee):
Address:
DCA Pedicab Business License Number:
Owner, Principal, or Officer Name:
Telephone Number:
Pedicab Registration Plate Number:
Pedicab Identifying Number (PID):
Manufacturer:
PEDICAB DRIVER LICENSEE INFORMATION
Name of Pedicab Driver (Licensee):
DCA Pedicab Driver License Number:
Telephone Number:
ACCIDENT INFORMATION
Date of Accident:
Approximate Time of Accident:
Place Where Accident Occurred:
1. Was anyone killed in the accident?
Yes
No
If Yes, print the name, telephone number, and address of the person(s) below, if known:
2. Did anyone sustain an injury requiring medical attention?
Yes
No
If Yes, print the name, telephone number, and address of the injured person(s) below and describe the nature of the injuries:
3. Was any property damaged, including the pedicab?
Yes
No
If Yes, print the name of the property owner, telephone number, and address below, with a brief description of the damaged property:
ACCIDENT INFORMATION (Continued)
Briefly describe how the accident occurred:
Describe actions taken after the accident:
WITNESSES
Name of Witness:
Address of Witness:
Telephone Number:
Name of Witness:
Address of Witness:
Telephone Number:
PEDICAB OWNER AFFIRMATION – Please read and sign below.
I affirm that I am the owner of the pedicab business or an agent duly authorized by the owner to complete and submit this form. I am responsible for the entries
made. I also affirm that I have personally reviewed all of the information entered, and it is true, correct, and complete to the best of my knowledge
Name of Pedicab Owner or Agent (Print):
Signature:
Date:
PEDICAB DRIVER AFFIRMATION – Please read and sign below.
I affirm that I am the pedicab driver involved in the accident described in this form. I am responsible for the entries made. I also affirm that I have personally
reviewed all of the information entered, and it is true, correct, and complete to the best of my knowledge.
Name of Pedicab Driver (Print):
Signature:
Date:
PENALTY FOR FALSE STATEMENTS: It is against the law to make a statement in this form that you know is false. If you make a statement that you know is
false, you may be punished.
Under Sections 210.45 and 175.30 of the New York Penal Law, you may be:
fined up to $1000 and / or
sent to jail for up to one year
Under Section 175.35 of the New York Penal Law, you may be punished if you:
make a statement that you know is false and / or
make the statement because you intend to mislead the Department of Consumer Affairs
Under Section 175.35 of the New York Penal Law, you may be:
fined up to $5000 or
fined an amount that is twice the amount of money you received by making the false statement and / or
sent to jail for up to 4 years
The Department of Consumer Affairs may also punish you for making a false statement on this form. These punishments may include:
fines or penalties of up to $500 for each false statement
permanent loss (revocation) of your license
09/2015
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