Consumer Request Form v.2

Motor Vehicle Record Request Form
You can use the electronic request below to obtain the most recent version of your motor vehicle record (MVR), if any, from Safety Holdings, Inc. It will also provide you with the details of any entities that received an MVR report in the two years prior to your request.
I am requesting a copy of my motor vehicle record.*

Yes
A photocopy of my valid Driver's License is attached as proof of my identity.*

Yes
We can not complete your Motor Vehicle Record Request Form without a photocopy of your valid driver's license. The reviewers must be able to read your license clearly to proceed with processing your request.
Attachments:*

Browse Files
Please attach a copy of your driver's license. (Limit 2MB. Allowed file types: .jpg .jpeg .png .pdf) Cancelof
Driver's License Information
Driver Full Name*

First NameMiddle NameLast Name
Driver Date of Birth*

MonthDayYear
Date
Driver's License Number*
Issuing State of Driver's License*
Your E-mail Address*

Confirmation Emailexample@example.com
Name of the employer/contracting company you are seeking employment OR the insurance company you are seeking coverage with. (This should be the company you believe ran your MVR)*
I give you permission to reply via secure email.*

YesNo
Since you do not wish to receive a reply via email, please fill out your mailing address below so that we can send your reply by mail.
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Signature*

Clear
Date Submitted to Safety Holdings, Inc.

MonthDayYear
Date
Please note that it can take up to 20 days to process a submitted request.

Submitting multiple requests will not expedite your request; all requests are worked in the order they are received.

This request is for a copy of your previously ordered MVR used by your employer, prospective employer, or insurance carrier. This request will NOT “re-run” your Motor Vehicle Record (MVR), nor will this process be remedied with your employer, potential employer, insurance companies, rideshare, delivery, and grey fleet contractors.

If you have had violations removed and/or corrected on your Motor Vehicle Record (MVR), please contact the company that ran your disputed Motor Vehicle Record (MVR) with adequately documented evidence of your cleared record.
Salesforce Business Hours ID:
Salesforce Owner ID:
Salesforce Case Type:
Salesforce Subject:
{yourName} - {salesforceCase35} - {dateSubmitted}
Issuing State of Driver's License
Should be Empty:

Motor Vehicle Record Request Form

Driver's License Information