Customer Notice of Consumer Dispute Form

Safety Holdings, Inc. Customer Dispute on behalf of Consumer Form:

To avoid any delays, the Customer must use the Safety Holdings, Inc. Notice of Consumer Dispute form and ensure that it is completed in its entirety. Disputes submitted to Safety Holdings, Inc. are intended to verify the motor vehicle record's accuracy, specifically, on the date your company requested it. If there have been changes since that date, a dispute will not capture those changes.
Please provide a specific description of the item(s) that are being disputed. In some instances, it might be beneficial to submit supporting documents along with your request.*

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Attachments:

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Consumer Information
Consumer Full Name*

First NameMiddle NameLast Name
Consumer Date of Birth*

YearMonthDay
Date
Consumer Driver's License Number*
Issuing State of Driver's License*
Are you applying to drive a vehicle weighing more than 20,000 lbs? Please select Yes or No below. (Note: This does not include passenger vehicles.)*

YesNo
Customer Information
Name of Your Company*

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Your Account Number*
Your Name*
Your Phone Number*

Area CodePhone Number
Your E-mail Address*

Confirmation Email
Date Submitted to Safety Holdings, Inc.

MonthDayYear
Date
Signature*

Clear
PLEASE NOTE THAT ALL DISPUTES ARE ANSWERED IN THE ORDER THAT THEY ARE RECEIVED.
Salesforce Business Hours ID:
Salesforce Owner ID:
Salesforce Case Type:
Salesforce Subject:
{yourName} - {salesforceCase35} - {dateSubmitted}
Issuing State of Driver's License
Should be Empty:

Safety Holdings, Inc. Customer Dispute on behalf of Consumer Form:

Consumer Information

Customer Information

PLEASE NOTE THAT ALL DISPUTES ARE ANSWERED IN THE ORDER THAT THEY ARE RECEIVED.