Form Fs-25 - Request For Insurance Information For Ny Registrants Involved In An Accident

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REQUEST FOR INSURANCE INFORMATION
Batch Number
FOR NY REGISTRANTS INVOLVED IN AN ACCIDENT
New York State Department of Motor Vehicles
Certified Document Center - Room 432e
6 Empire State Plaza
Albany, New York 12228
REQUESTER’S NAME AND ADDRESS (Please Print)
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.
DMV Search Account Number __________________________
Name ______________________________________________
Address ____________________________________________
____________________________________________
Requester’s File # __________________________________
Check all appropriate boxes to specify the items you want:
For all records
, the Federal Driver’s Privacy
o
other than your own
Insurance information search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10
Protection Act (DPPA) regulates access to Motor Vehicles records.
So you
o
must tell us why you want the records you are requesting.
In addition to
FH Certificate (for-hire vehicles)—certified copy. . . . . . . . . . . . . . $11
o
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.
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*
M.I.
Date of Birth (Month/Day/Year)
Registrant’s Last Name
/
/
Registrant’s Mailing Address (Include Street & No.)
Apt. No.
City
State
Zip Code
First
M.I.
Date of Birth (Month/Day/Year)
Driver’s Last Name
/
/
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:
o Amended
o The FS Insurance ID Card or FH Certificate is not available.
o This information is not available because the vehicle is not registered in New York.
o A
ccording 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:
l
A COPY OF THE COMPANY’S DENIAL LETTER (ON COMPANY LETTERHEAD), AND
l
A COPY OF THE ACCIDENT REPORT
o
Insurance coverage was not in effect on the date of the above accident. Please see item A on form FS-25.1.
o
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.
o
See form FS-25.1 for the reason we are unable to process your request at this time.
Processed by
Date
PAGE 1 OF 2
FS-25 (7/15)

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