Insurance MVR Document

Motor Vehicle Record (MVR) Authorization — Insurance Use

Client Name:

Applicant / Insured Information

Date of Birth:

Driver's License Number:    State of Issue:

License Issue Date:

License Expiration Date:

Policy Details

Policy Type: Auto Liability Physical Damage Personal Injury Protection Other:

Coverage Limit: $    Deductible: $    Premium: $

Policy Period From:    To:

MVR Records Requested

The undersigned authorizes the release of the following categories of driving history to the insurer and its agents for underwriting, rating, claims handling, and renewal purposes. Select all that apply.

Full Motor Vehicle Record (all entries)
Convictions and Point History
Accident/Collision Report History
Suspensions and Revocations
Citation and Ticket History
Commercial/For-Hire Driving Records (if applicable)
Other:

Exclusions and Limitations

By checking the box below, the applicant indicates that no special exclusions beyond those stated above should limit the MVR disclosure.

Beneficiary Designation (if applicable)

Authorization, Disclosure and Certification

I certify that the information provided on this form is true and correct to the best of my knowledge. I authorize the insurer named above, its agents, representatives, and reinsurers to obtain my Motor Vehicle Record (MVR) and related driving history information from any state motor vehicle agency, law enforcement agency, or private database for underwriting, rating, claims handling, fraud investigation, and renewal evaluation purposes.

I further authorize the release of previously reported or archived driving record information and any records necessary to corroborate the driving record. This authorization expressly includes the release of conviction, accident, suspension, revocation, and citation information for the person named above. A photocopy or electronic reproduction of this authorization shall be as valid as the original.

This authorization is valid for a period of one (1) year from the date of signature below or for the duration of the policy period identified above, whichever is longer, unless earlier revoked in writing. Revocation will not affect disclosures made prior to receipt of written revocation.

Applicant's Certification: I understand that information obtained pursuant to this authorization may be used in whole or in part to: determine eligibility for coverage, set rates, investigate claims, and verify information contained in any application for insurance. I further acknowledge receipt of any required privacy or disclosure notices provided by the insurer at the time of signing.

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