DL-9106 (10-13)
Legal Business Name: _______________________________________________________________________________________________________________
D/B/A Name(if applicable): ____________________________________________________________________________________________________________
Person Responsible: Name: ______________________________________________________________ Title: _______________________________________
Physical Address: __________________________________________________________________________________________________________________
City: __________________________________________________________________________________State: _________________ Zip: _________________
Business Telephone: ____________________________________________ Fax No.: ________________________________________________________
E-mail: _________________________________________________________ Website Address: __________________________________________________
Federal Employer ID No.: _______________________________If Corporation, Date & State of Incorporation: _________________________________________
Year Business Established: ______________________ Dun & Bradstreet #: _______________________ NAIC #: ________________________(if applicable)
Licensing Information: Cert. of Insurance/Authority #: ______________________________________________ State: __________ Expires: _____________
(List & attach copy
Agency or Brokerage License #: ____________________________________________ State: __________ Expires: _____________
with affidavit.) Agent or Broker License #: ________________________________________________ State: __________ Expires: _____________
Location of Records: For departmental on-site inspection, audit and review purposes. o Check here, If address is same as above.
Street Address: ____________________________________________ City: __________________________________ State: _________ Zip: ______________
Ownership: List below individual, each partner, or each corporate officer participating in the direction, control or management of the business.
Attach list if needed.
Name (Last, First, MI) Title Date of Birth Driver License Day-Time
(MM/DD/YYYY) STATE Phone Number
1.
2.
3.
Please initial each statement below and sign at the bottom of the form.
______ 1. I swear and affirm that any requested information will be used for legitimate insurance business only.
______ 2. I swear and affirm that I understand the driver record is confidential and restricted information and I will establish procedures to protect the
confidentiality of these records.
______ 3. I swear and affirm that I will not request driver information from the Department for personal reasons. (Examples of inappropriate
access or misuse of Department information include, but are not limited to: making personal inquiries on my own record or those of my
relatives; accessing information about another person, including locating their residence address, for any reason that is not related to my
job responsibilities.)
______ 4. I swear and affirm that the information obtained from the Department shall not be sold, assigned or otherwise transferred to any other party.
I understand that nothing in this affidavit shall be interpreted to restrict an insurance company from providing the information to its exclusive
licensed insurance agents or an insurance agent from providing the information to an insurance company for legitimate insurance business.
______ 5. I swear and affirm that I understand that the Department retains exclusive ownership of all driver record information provided and no record shall
be combined and/or linked in with any other data on any database except as is necessary to conduct legitimate insurance business or as may
be required by law.
______ 6. I swear and affirm that the information obtained from the Department will not be used for direct mail advertising or any other type or types of mail
or mailings.
______ 7. I swear and affirm that I will not disseminate or publish on the Internet the personal information obtained from the Department or allow any other
person to disseminate or publish the personal information on the Internet without the express written permission of the Department.
______ 8. I swear and affirm that the statements made herein are true and correct, and that any statement made on or pursuant to this form is subject to
the penalties of 18 PA C.S. Section 4903(a)(2) (relating to false swearing), which shall include punishment of a fine not exceeding $5,000, or a
term of imprisonment of not more than two years, or both.
Signature Date
Title
S
E
A
L
Subscribed and Sworn
to Before Me: Mo. Day Year
Sign in Presence of Notary
Signature of Person Administering Oath
INSURANCE COMPANY/AGENCY AFFIDAVIT OF INTENDED USE
INFORMATION SALES UNIT
(See Reverse Side for Instructions)
Business Type (check one):
q
Individual
q
Partnership
q
Corporation
q
Non-Profit
Account Number:
iiX PAI Account # 7
