New York State Department of Motor Vehicles Certified Document Center - Room 432e 6 Empire State Plaza Albany, New York 12228 Batch Number REQUEST FOR INSURANCE INFORMATION FOR NY REGISTRANTS INVOLVED IN AN ACCIDENT Attach a check or money order (payable to the Commissioner of Motor Vehicles) for the total amount; or, if you have an established DMV search account and want to charge this search, please provide the search account number, your file number for this request, and the name and address of the account to be charged. REQUESTER’S NAME AND ADDRESS (Please Print) DMV Search Account Number __________________________ Name ______________________________________________ Address ____________________________________________ ____________________________________________ Requester’s File # __________________________________ Check all appropriate boxes to specify the items you want: For all records other than your own, the Federal Driver’s Privacy Protection Act (DPPA) regulates access to Motor Vehicles records. So you FH Certificate (for-hire vehicles)—certified copy. . . . . . . . . . . . . . $11 must tell us why you want the records you are requesting. In addition to completing the information below, check the boxes on page 2 that describe FS Insurance ID Card—certified copy. . . . . . . . . . . . . . . . . . . . . . . $11 your use for the records you are requesting, and sign the certification. Insurance information search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10 Enter all available information below. If any required information (noted by *) is missing, we will not be able to process your request. Date of Accident (Month/Day/Year)* Year and Make of Vehicle* Plate Number* / / First* Registrant’s Last Name* M.I. Date of Birth (Month/Day/Year) / Registrant’s Mailing Address (Include Street & No.) Apt. No. City First Driver’s Last Name State / Zip Code Date of Birth (Month/Day/Year) M.I. / Driver’s Mailing Address (Include Street & No.) Apt. No. City State / Zip Code Driver of Other Vehicle (THIS BOX IS TO BE COMPLETED ONLY BY DMV STAFF) YOUR REPLY FROM THE DEPARTMENT OF MOTOR VEHICLES IS AS FOLLOWS: Amended The FS Insurance ID Card or FH Certificate is not available. This information is not available because the vehicle is not registered in New York. According to our records, insurance coverage with the following company was in effect on the date of the above accident: Insurance Company: __________________________________________________________________________________________ Policy Number (if available): __________________________________________________________________________________ IF THE INSURANCE COMPANY NAMED ABOVE DENIES COVERAGE FOR THIS ACCIDENT, SEND THE FOLLOWING TO THE DMV INSURANCE SERVICES BUREAU AT THE ADDRESS AT THE TOP OF THIS PAGE: A COPY OF THE COMPANY’S DENIAL LETTER (ON COMPANY LETTERHEAD), AND A COPY OF THE ACCIDENT REPORT Insurance coverage was not in effect on the date of the above accident. Please see item A on form FS-25.1. Insurance coverage was not in effect on the date of the above accident. DMV will initiate revocation action against the registrant and/or driver for being in an uninsured accident. You will be notified within 90 days. See form FS-25.1 for the reason we are unable to process your request at this time. Processed by FS-25 (3/11) Date PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com List of Permissible Uses for Personal Information Under the Federal Driver’s Privacy Protection Act: 1. Use in the normal course of business by a legitimate business or its agents, employees, or contractors ONLY: N to verify the accuracy of personal information submitted by an individual to the business; AND N if such submitted information is not correct or is no longer correct, to obtain the correct information, BUT ONLY for the purposes of preventing fraud by, pursuing legal remedies or recovering on a debt or security interest against, the individual. 2. Use in connection with any civil, criminal, administrative, or arbitral proceeding in any federal, state or local court or agency, or before any self-regulating body, including: N the service of process; N investigation in anticipation of litigation; N the execution or enforcement of judgments and orders; OR N pursuant to an order of a federal, state or local court 3. Use by any government agency, including any court or law enforcement agency, in carrying out its functions, or by any private person or entity acting on behalf of a federal, state, or local agency in carrying out its functions. 4. Use in providing notice to the owners of towed or impounded vehicles. 5. Use by any insurer or insurance support organization, or by a self-insured entity, or its agents, employees or contractors in connection with: N claims investigation activities; N anti-fraud activities; N rating; or N underwriting. 6. Use by a licensed private investigative agency or licensed security service for any purpose permitted under the DPPA. 7. Use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver’s license that is required under the Commercial Motor Vehicle Safety Act of 1986. 8. Use by any requester if the requester provides written consent from the individual to whom the information pertains. 9. Use in the following matters, as long as the personal information is not published, redisclosed or used to contact individuals: N research activities; and N producing statistical reports. 10. Use in connection with matters of: N motor vehicle or driver safety and theft; N motor vehicle emissions; N motor vehicle product alterations, recalls, or advisories; N performance monitoring of motor vehicles, motor vehicle parts and dealers; N motor vehicle market research activities, including survey research; and N removal of non-owner records from the original owner records of motor vehicle manufacturers. 11. Use specifically authorized under New York State law if such use is related to the operation of a motor vehicle or public safety. Check the appropriate box or cite the law here: 11(a) Article 19A 11(d) (other)_____________________________________ 11(b) Article 19B 11(c) Kieran’s Law 12. Use to carry out the purposes of Titles I and IV of the Anti-Car Theft Act of 1992, the Automobile Information Disclosure Act (15 U.S.C. 1231, et.seq.), the Clean Air Act (42 U.S.C. 7401, et.seq.) and Chapters 301, 305 and 321 - 331 of Title 49 (49 U.S.C.S. 30101, et.seq.; 30501, et.seq.; 32101,et.seq.; 33101, et.seq.), in connection with matters of: N motor vehicle or driver safety and theft; N motor vehicle emissions; N motor vehicle product alterations, recalls or advisories; N performance monitoring of motor vehicles and dealers by motor vehicle manufacturers; and N removal of non-owner records from the original owner records of motor vehicle manufacturers. 13. Use in connection with the operation of private toll transportation facilities. 14. Use for any other purpose: N license records without the motorist’s address. These records include either the client identification number or the driver’s name and date of birth, if such information has been provided by the requester. I certify that I shall use or redisclose the information provided by DMV only for the use described in the box(es) checked on this form, and that I will comply fully with the Driver’s Privacy Protection Act (18 USC Sec. 2721, et seq). I also agree to defend, hold harmless and indemnify DMV from all actions brought against DMV, or damages alleged against DMV, for my negligent, improper or unauthorized use or dissemination of the information provided by the DMV. Signature ± ____________________________________________________ Print Name ______________________________________________________ Date ________________________ Your Date of Birth ___________________ To knowingly make a false statement or conceal a material fact in this written statement is a criminal offense, punishable under Penal Law Section 210.45. In addition, anyone who makes false representation to obtain any personal information from an individual’s Motor Vehicles record is subject to federal criminal fines under the Driver’s Privacy Protection Act (DPPA). FS-25 (3/11) www.dmv.ny.gov PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com