Driver Abstract/Claims Experience
Letter Request Form
DRIVER INFORMATION
DRIVER’S SIGNATURE* ________________________________________________ DATE ________________________
*
A photocopy or other electronic copy of this signed authorization shall have the same authority as the original.
PAYOR INFORMATION
– IF DIFFERENT FROM DRIVER
If requested by mail, please include a cheque or money order payable to Manitoba Public Insurance or provide credit card
information below.
If requested by fax, please provide the following credit card information:
OFFICE USE ONLY:
Fee Paid
REV (01/21)
Name: ____________________________________________________________________________________________
Last Name First Name Middle Initial
Individual / Company Name:
Company Contact Name:
Phone Number: _______________________________
VISA / MasterCard Number: __________________________________________________________________________
Card Expiry Date: _________________ Card Holder Signature: ______________________________________________
Month
Day
Year
Date of Birth: ______/_______/______
Driver's Licence Number: ____________________________
Telephone Number: ________________
Return Fax Number or Address: ________________________________________________________________________
Document Requested (Check all that apply):
Driver Abstract $10 Commercial Driver Abstract $10
Claims Experience Letter $15
AUTHORIZATION TO DISCLOSE DRIVER INFORMATION
FOR MORE INFORMATION CALL: 204-985-7000 or TOLL FREE: 1-800-665-2410
SUBMIT FORM BY MAIL: Manitoba Public Insurance, Driver Records and Suspensions, Box 6300, Winnipeg, MB, R3C 4A4
SUBMIT FORM BY FAX: 204-985-8105 or TOLL FREE: 1-866-317-3267
$20
I
ndividual / Company Name:
________________________________________________________________________
Address:
________________________________________________________________________________________
Fax Number:
_______________________________
I
hereby authorize Manitoba Public Insurance to disclose the requested documents to the individual/company noted below
as
f
ollows(select applicable)
Upon request by the individual/company for a period of two years from date signed. I understand I may
revoke this authorization at any time by notifying the individual/company named below.
$25
$10
$15
One time use within 30
days from date signed
(if applicable)
