APPLICATION FOR A MOTOR VEHICLE BODY DAMAGE ESTIMATOR LICENSE If you are not licensed by the NYS Insurance Department, complete this form. NOTE: Do not complete this form if you currently hold a NYS Independent Adjuster's License for General, Automobile-All Coverages, or Automobile Damage and Theft Appraisal. G FOR OFFICE USE ONLY EIA EIO EIC EIS County EIG EID License Number OE Y N ADD N Y FOR ORIGINAL APPLICATIONS Answer ALL questions on pages 1 and 2 that apply to you, and SIGN the application on page 2. An estimator's license will be issued only to someone who has: at least one year of training and/or experience in body repair cost estimating for a registered repair shop; or at least one year of training and/or experience in adjusting body repair claims for an insurance company or independent adjuster; or a degree in automotive technology from an accredited college or university or vocational school, and at least six months of experience in body repair cost estimating for a registered repair shop. TO AMEND OR REPLACE YOUR ESTIMATOR LICENSE Answer questions 1-20 below, and SIGN the application on page 2 (No. 24). G RETURN APPLICATION AND PAYMENT TO: ORIGINAL APPLICATION FEES Non-refundable application fee. . . . . . . . . . . $ 25 BUREAU OF CONSUMER AND FACILITY SERVICES Three-year license fee . . . . . . . . . . . . . . . . . . $150 PO Box 2700-ESP Total amount due. . . . . . . . . . . . . . . . . . . . . . $175 Albany NY 12220-0700 Each fee must be paid with a separate check or money order Telephone (518) 474-7998 payable to the Commissioner of Motor Vehicles. Please Print or Type in the spaces next to the arrows. G 1± Check type of application: ORIGINAL AMENDMENT (No Fee) REPLACEMENT (No Fee) Have you ever been a Certified Motor Vehicle Inspector and/or a Licensed Body Damage Estimator? 2± Yes No Expiration Date____________________ Day Year M F If "YES", give your Certification/License No. _________________________________________ LAST NAME FIRST M.I. DATE OF BIRTH 3± MAILING ADDRESS NUMBER (include street no., rural delivery, and/or box no.) APT. NO. 4± 6 MAILING ADDRESS STREET NAME Month / HEIGHT Feet / Inches 5± EYE COLOR 6± 9± CITY OR TOWN STATE ZIP CODE 7± 10± ( 8± HOME TELEPHONE NUMBER (include area code) ) COUNTY 11± (if different from mailing address) NUMBER AND STREET (include rural delivery, box no. and/or apartment no.) 12± HOME ADDRESS CITY STATE ZIP CODE 13± 14± Has your address changed since your last driver license was issued? Yes No CLIENT I.D. NUMBER (from NewYork State driver license or non-driver ID) NOTE: Failure to provide a valid Client ID will prevent issuance of a Body Damage Estimator License. 15± PLEASE CONTINUE, AND SIGN ON PAGE 2 Check this box if you do not currently have a New York State driver license or non-driver ID. A form (ID-5 VSBDE) will be mailed with instructions on how to obtain a Client ID. VS-117 (10/15) *VS-117* PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com PRESENT EMPLOYER FACILITY NUMBER (if applicable) BUSINESS TELEPHONE NUMBER 16± BUSINESS ADDRESS 17± (NUMBER AND STREET) CITY 18± ( ) ZIP CODE STATE 19± 20± (FOR ORIGINAL APPLICATIONS ONLY) Have you ever been convicted of any felony or misdemeanor? Yes No If "YES", give details below: (Applicants will not necessarily be rejected because of a conviction record. Each record will be reviewed on an individual basis.) Date of Violation What is the Violation? Date of Conviction Disposition & Fine Court Location 21± (FOR ORIGINAL APPLICATIONS ONLY) List all motor vehicle body damage estimator experience: Employer's Name and Address Type of Work Dates (From - To) 22± (FOR ORIGINAL APPLICATIONS ONLY) List any trade school, vocational school, or other motor vehicle repair courses taken. A copy of your diploma must be provided with this application if you have less than one year of work experience. School Name and Address Type of Course Type of Degree Dates of Attendance Section 398(d) of the Vehicle & Traffic Law authorizes the licensing of motor vehicle body damage estimators. Anyone who has such a license agrees to comply with the rules and regulations promulgated by the Commissioner of Motor Vehicles. Failure to comply with these rules and regulations may result in the revocation of this license. Notify this office of any change in your address. FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW. NAME (PLEASE PRINT) __________________________________________________________ Date_________________ (Sign Name in Full - DO NOT PRINT - No Nicknames) 23± SIGNATURE __________________________________________ VS-117 (10/15) www.dmv.ny.gov PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com