MARYLAND STATE FORM INSTRUCTIONS
The following information will assist you in completing the form to access MVRs in this state.
Please note the state will return the form if not filled out per the below instructions.
Be sure to write your Insurance Information Exchange Account Number on the upper
right hand corner of form.
Fill in your agency/company name on the first blank line provided in the first paragraph.
Fill in the day, month and year on the appropriate lines in the first paragraph.
Fill in your agency/company name on ALL blank lines in paragraphs #1,3,4,5,6 and 7.
Note the name must be the same in all name blanks.
On second page please sign under the word Purchaser on the right side of form. Only
a person who is authorized to execute contracts for your company should complete an
d
si
gn this form. Please sign in the presence of a witness, and date the form on the line
provided under your signature.
Since the state of Maryland will not accept the form when the signature is illegible, we
r
equest that you also print your name under the word Purchaser
.
The witness should then sign under “Witness” on the left side of form and date the
form on the line provided. Both dates must be the same
.
Mail, Fax or Email forms to:
IntelliCorp
3000 Auburn Drive, Suite 410
Beachwood, OH 44122
Attn: MVR Compliance
Fa
x: 216-450-5249
Email: MVRCompliance@Intellicorp.net
iiX Customer Acct #
iiX User number X2815
STATE OF MARYLAND
DEPARTMENT OF TRANSPORTATION
MOTOR VEHICLE ADMINISTRATION
PRIVACY PROTECTION POLICY
In consideration of receiving personal information contained in Motor Vehicle
Administration records, I HEREBY CERTIFY on behalf of as its
authorized agent this day of , 20 , that
1.
understands that federal laws affect access to and use
of computer information including, but not limited to, 15 U.S.C.A. § 278g-3
(Computer Security Act of 1987); 23 U.S.C.A. § 401 (National Driver Register Act);
5 U.S.C.A. § 552 (Freedom of Information Act); 5 U.S.C.A. § 552a (Privacy Act of
1974); 18 U.S.C.A.§ 1001 (Computer Fraud and Abuse Act of 1986); 17 U.S.C.A. §
109 (Computer Software Rental Amendments Act of 1990); 15 U.S.C.A. § 1681 (Fair
Credit Reporting Act); and, 18 U.S.C.A. §§ 2721 et seq. (Driver’s Privacy Protection
Act of 1994).
2.
The Maryland Department of Transportation Office of Information Resources, its
client agencies and their customers also adhere to state data processing security
policies as set forth in Executive Order 01.01.1983.18 (Privacy and State Data
System Security); Md. Code Ann., Crim. Law §8-606 (falsification of public records)
and §7-302 (unauthorized access); Md. Code. Ann., State Gov’t §§ 10-611, 10-616
and 10-626 (Maryland Public Information Act); Md. Code Ann. Transp. II §§ 12-111
to 12-113 (Motor Vehicle Administration Records); and, as published by the
Secretary of the Department of Budget and Management from time to time under Md.
Code Ann., State Fin. & Proc. § 3-403.
3.
and all employees agree to maintain in strictest
confidence and not willfully disclose to any person, firm, or corporation information
obtained as a result of their access to personal information from Motor Vehicle
Records.
4.
By signing this agreement, warrants that the
signator and all personnel are familiar with all provisions of the federal Driver
Privacy Protection Act of 1994, 18 U.S.C.A. §§ 2721 et seq., and with §§ 10-611, 10-
616, 10-626 of the State Government Article and §§ 12-111 through 12-113 of the
Transportation Article, Annotated Code of Maryland, which limit access to personal
information from public records in Maryland. Further,
, in behalf of itself, its successors and assigns further
agrees that all users will abide by the terms of both the federal and state law
including, but not limited to, those restricting access to personal information from
Motor Vehicle Administration records only to those persons and for those purposes
which are permitted under both laws.
iiX Customer Acct #
iiX User number X2815
5.
agrees to keep a record for five (5) years of all
persons to whom information is redisclosed under this Agreement, and the purpose
for which the information is to be used; and, to make that record available to the
Motor Vehicle Administration upon request.
6.
shall be liable for, and shall indemnify, defend, and
hold the Motor Vehicle Administration harmless for, any misuse or misappropriation
of any personal information in a record obtained from the Administration in
connection with this agreement.
7.
shall further indemnify the Motor Vehicle
Administration for and against any and all losses, damages, judgments, liabilities or
similar costs and expenses which arise in whole or part out of acts or omissions by
with respect to laws restricting access to and
disclosure of vehicle records including, without limitation, reasonable attorneys fees
and all other costs of defending against such action or claim.
IN WITNESS WHEREOF, the parties have caused these presents to be executed.
Maryland Department of Transportation
Witness: Motor Vehicle Administration
By:
Date: Date:
Witness: Purchaser
By:
Date: Date:
Approved as to form and legal sufficiency:
Date:
Assistant Attorney General REV: 07/2010