Consumer Dispute Form

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Please attach a copy of your driver's license and any supporting documentation. (Limit 2MB. Allowed file types: .jpg .jpeg .png .pdf) Cancelof
Safety Holdings, Inc. Consumer Dispute Form:

PLEASE NOTE THAT SUBMITTING MORE THAN ONE DISPUTE WILL DELAY THE PROCESS.
This version of this form is out of date. Please access the new form version at the link below:

https://forms.sambasafety.com/233207185398967
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*
Your Phone Number*

Area CodePhone Number
Your E-mail Address*

Confirmation Email
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name of Employer or Insurance Company who ordered your motor vehicle record.*
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
I give you permission to reply via secure email.*

YesNo
Signature*

Clear
Date Submitted to Safety Holdings, Inc.

MonthDayYear
Date
A clear image of your driver's license or passport MUST be uploaded in order for us to proceed with your dispute.
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:
Issuing State of Driver's License
Should be Empty:

Safety Holdings, Inc. Consumer Dispute Form: