Form Fs-25 - Request For Insurance Information For Ny Registrants Involved In An Accident Page 2
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2List of Permissible Uses for Personal Information Under the Federal Driver’s Privacy Protection Act:
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1.
Use in the normal course of business by a legitimate business or its agents, employees, or contractors ONLY:
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to verify the accuracy of personal information submitted by an individual to the business; AND
if such submitted information is not correct or is no longer correct, to obtain the correct information, BUT ONLY for the
u
purposes of preventing fraud by, pursuing legal remedies or recovering on a debt or security interest against, the individual.
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2.
Use in connection with any civil, criminal, administrative, or arbitral proceeding in any federal, state or local court or agency, or
before any self-regulating body, including:
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the service of process;
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investigation in anticipation of litigation;
the execution or enforcement of judgments and orders; OR
pursuant to an order of a federal, state or local court
u
u
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3.
Use by any government agency, including any court or law enforcement agency, in carrying out its functions, or by any private person
or entity acting on behalf of a federal, state, or local agency in carrying out its functions.
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4.
Use in providing notice to the owners of towed or impounded vehicles.
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5.
Use by any insurer or insurance support organization, or by a self-insured entity, or its agents, employees or contractors in connection with:
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claims investigation activities;
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anti-fraud activities;
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rating; or
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underwriting.
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6.
Use by a licensed private investigative agency or licensed security service for any purpose permitted under the DPPA.
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7.
Use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver’s license that is
required under the Commercial Motor Vehicle Safety Act of 1986.
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8.
Use by any requester if the requester provides written consent from the individual to whom the information pertains.
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9.
Use in the following matters, as long as the personal information is not published, redisclosed or used to contact
individuals:
research activities; and
producing statistical reports.
u
u
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10. Use in connection with matters of:
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motor vehicle or driver safety and theft;
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motor vehicle emissions;
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motor vehicle product alterations, recalls, or advisories;
performance monitoring of motor vehicles, motor vehicle parts and dealers;
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motor vehicle market research activities, including survey research; and
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removal of non-owner records from the original owner records of motor vehicle manufacturers.
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11. Use specifically authorized under New York State law if such use is related to the operation of a motor vehicle or public safety. Check the
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o
o
appropriate box or cite the law here:
11(a) Article 19A
11(b) Article 19B
11(c) Kieran’s Law
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11(d) (other)_____________________________________
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12. Use to carry out the purposes of Titles I and IV of the Anti-Car Theft Act of 1992, the Automobile Information Disclosure Act
(15 U.S.C. 1231, et.seq.), the Clean Air Act (42 U.S.C. 7401, et.seq.) and Chapters 301, 305 and 321 - 331 of Title 49 (49 U.S.C.S. 30101,
et.seq.; 30501, et.seq.; 32101,et.seq.; 33101, et.seq.), in connection with matters of:
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motor vehicle or driver safety and theft;
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motor vehicle emissions;
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motor vehicle product alterations, recalls or advisories;
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performance monitoring of motor vehicles and dealers by motor vehicle manufacturers; and
removal of non-owner records from the original owner records of motor vehicle manufacturers.
u
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13. Use in connection with the operation of private toll transportation facilities.
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14. Use for any other purpose:
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license records without the motorist’s address. These records include either the client identification number or the driver’s name and
date of birth, if such information has been provided by the requester.
I certify that I shall use or redisclose the information provided by DMV only for the use described in the box(es) checked on this form, and
that I will comply fully with the Driver’s Privacy Protection Act (18 USC Sec. 2721, et seq). I also agree to defend, hold
harmless and indemnify DMV from all actions brought against DMV, or damages alleged against DMV, for my negligent, improper or
unauthorized use or dissemination of the information provided by the DMV.
ç
Signature
____________________________________________________
Date ________________________
Print Name ______________________________________________________
Your Date of Birth ___________________
To knowingly make a false statement or conceal a material fact in this written statement is a criminal offense, punishable under Penal Law
Section 210.45. In addition, anyone who makes false representation to obtain any personal information from an individual’s Motor Vehicles
record is subject to federal criminal fines under the Driver’s Privacy Protection Act (DPPA).
PAGE 2 OF 2
FS-25 (7/15)
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