REQUEST and REPLY FOR NEW YORK INSURANCE INFORMATION
Certified Document Center
6 Empire State Plaza
Albany, New York 12228
”
”
PRINT YOUR NAME AND RETURN ADDRESS BELOW
* THERE IS A $10.00 SEARCH FEE REQUIRED BY LAW *
PAYMENT METHOD
l
D
O NOT SEND CASH l
o
DMV Dial-in account number ___________________
o
o
o
Check
Money Order
Exempt
Payable to the “Commissioner of Motor Vehicles”
Daytime Phone Number (
required
):
ENTER THE INFORMATION NEEDED TO COMPLETE THE INSURANCE SEARCH (* REQUIRED)
*
*
*
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
/
/
ü If our records show that the vehicle was properly insured on the date of the accident, we will send you the name of the
insurance company. You must then contact the insurance company to resolve your claim. If the insurance company tells
you the vehicle was not insured on the date of the accident, you must get a letter from the insurance company denying
coverage. DMV will review the information and take appropriate action.
ü If our records show that the vehicle did not have insurance coverage on the date of the accident, we will notify you. Your
request and accident report will be forwarded directly to the Insurance Services Bureau.
”
”
DMV USE ONLY
YOUR REPLY FROM THE DEPARTMENT OF MOTOR VEHICLES IS AS FOLLOWS
DMV USE ONLY
£
On the date of accident requested, DMV’s records show insurance coverage was in effect with:
Insurance Company: ________________________________________________________________________________
Policy Number : _________________________________
(if available)
£
UPDATED
Insurance Information (this updates previous insurance information):
IF THE INSURANCE COMPANY DENIES COVERAGE FOR THIS ACCIDENT, SEND A COPY OF THE COMPANY’S DENIAL LETTER
AND A COPY OF THE ACCIDENT REPORT TO: Insurance Services Bureau, 6 Empire State Plaza, Albany, NY 12228.
FS-25 (12/16)
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