Consumer Dispute Form v.3

Please choose the option that most accurately describes your dispute regarding your Motor Vehicle Record

License Status (including CDL downgrades)Moving violationsDUI/DWIsTraffic ticketsAccidents (we cannot verify accident fault only the existence of an incident)

Select "License Status" if you believe your driver's license was incorrectly reported. For example, your license was listed as "expired," "invalid," or similar, and you believe that status was inaccurately reported. Another example may be that your CDL was downgraded, and you believe the status was inaccurately reported.

Select "Moving Violations," "Traffic tickets," and/or "Accidents" if you believe an accident, traffic ticket, or similar violation or citation was incorrectly reported on your MVR. Remember that dismissed cases are still reportable by the States' DMVs, and accidents are reported regardless of fault, and we cannot verify that. Expungement is the only judicial process to remove any derogatory information in your MVR.

Select "DUI/DWIs" if you believe that a DUI/DWI was incorrectly reported on your MVR. Remember that dismissed cases are still reportable by the States' DMVs, and accidents are reported regardless of fault, and we cannot verify that. Expungement is the only judicial process to remove any derogatory information in your MVR.

Please provide a description of the item(s) you are disputing below*

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A clear image of your driver’s license must be uploaded in order for us to proceed with investigating your dispute.

Attachments:*

Browse Files

Please attach a copy of your driver's license and any supporting documentation. (Limit 2MB. Allowed file types: .jpg .jpeg .png .pdf)

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

Yes

Driver Full Name*

First NameMiddle NameLast Name

Driver Date of Birth*

MonthDayYear

Driver's License Number*

Issuing State of Driver's License*

Your E-mail Address*

Confirmation Email

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)*

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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

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

Please note that it can take up to 30 days to process a submitted dispute.

Submitting multiple requests will not expedite your dispute and all disputes are worked in the order they are received.

The dispute process is only intended to research the last ordered record by your employer, insurance company, and contract-for-hire companies (rideshare, delivery, etc).

This dispute process does not “re-run” your Motor Vehicle Record (MVR) nor will this dispute process remediate 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 reach out to the company that ran your disputed Motor Vehicle Record (MVR) with proper documented evidence.

Signature*

Date Submitted to Safety Holdings, Inc.

Date

Salesforce Business Hours ID:

Salesforce Owner ID:

Salesforce Case Type:

Salesforce Subject:

Issuing State of Driver's License

Motor Vehicle Record Dispute Form

Driver Information