Insurance
ATTACHMENT D
Subscriber Certification of Use
Use this form to certify the Subscriber’s use of Washington State Department of Licensing data.
Choose one:
Insurance company
I hereby certify:
1.
The insurance carrier to which the named individual has applied for motor vehicle insurance or life insurance and/or has life
insurance in effect covering the named individual.
2.
The insurance carrier or the agent of the insurance carrier designated below as Subscriber:
a.
Has motor vehicle insurance in effect covering the employer or a prospective employer; or
b.
Has motor vehicle insurance in effect covering the named individual; or
c.
Is the insurance carrier to which the employer or prospective employer has applied for motor vehicle insurance.
3.
iiX, a unit of ISO Claims Services, Inc. is acting as agent for Subscriber.
4.
Abstract Driver Records shall be used exclusively for our insurance underwriting purposes only, and that no information
contained therein shall be divulged, sold, assigned, or otherwise transferred to any third person or party.
5.
The information contained in the abstracts of driver records obtained from the Department shall be used in accordance with
the requirements and in no way violate the provisions of RCW 46.52.130, attached in part for easy reference.
☐ Employer / Transit authority / Volunteer organization
I hereby certify:
1.
The company or their agent designated below as Subscriber is an employer, prospective employer, a volunteer organization,
or a transit authority for its vanpool program.
2.
(company name) is acting as agent for Subscriber.
3.
Abstracts of driver records shall be used exclusively for determining:
a.
Whether the volunteer licensee meets those insurance and risk management requirements necessary to drive a vanpool
vehicle, or
b.
Whether an employee, prospective employee, or volunteer should be employed to operate a vehicle or for employment
purposes related to driving by an individual as a condition of that individual’s employment upon the public highways.
4.
No information contained therein shall be divulged, sold, assigned, or otherwise transferred to any third person or party.
5.
The information contained in the abstracts of driver records obtained from the Department shall be used in accordance with
the requirements and in no way violate the provisions of RCW 46.52.130.
The Subscriber listed below agrees to, and shall indemnify and hold harmless the state of Washington, Department of Licensing (DOL),
the Director of DOL and all DOL employees from any and all suits at law or equity, and from any and all claims, demands or loss of any
nature, including but not limited to all costs and attorney fees, arising from any incorrect or improper disclosure of individual names or
addresses under this “Subscriber Certification of Use;” any defects in any of Subscriber’s procedures followed or omitted or arising from
the failure of Subscriber or its officers, employees, customers, contractors or agents to fulfill any of its obligations under this Contract; or
arising in any manner from any negligent act or omission by Subscriber or its officers, employees, customers, contractors or agents.
I affirm that I am a representative authorized to bind the Subscriber named below.
Authorized representative name
X
Date and place signed Authorized representative signature
CP-520-520 (N/2/13)E
Insurance Information Exchange, a unit of ISO Claims Services, Inc. Created on 07/23/15
1716 Briarcrest, Suite 200 Bryan, TX 77802 Version WAI2015.1
800-683-8553 FAX (201) 748-1449
