Authorized Insurer Signature
Name of Insurance Company
INSURANCE COMPANY - If you are an insurance company please complete this section.
To comply with this requirement, please provide iiX with your NAIC number. If your company holds
more than one NAIC number, please provide the NAIC number for the carrier that you most utilize for
Nevada business.
Name of Insurance Company
Your Agency/Brokerage Name
INSURANCE AGENT/BROKER - If you are an insurance agent/broker please complete this section.
To comply with this requirement, please provide iiX with the NAIC number of the insurance company
for which you will be primarily ordering MVRs. If you represent multiple insurance companies,
provide the NAIC number for the company that you most utilize for Nevada business.
This NAIC number will be stored for you at iiX and provided to the Nevada DMV when you order
driver records. Should you need to provide the NAIC number of another insurance company, you will
have the ability to submit a different NAIC number at the time of your order.
iiX NEVADA NAIC FORM
Insurance Account number
In compliance with Nevada Administrative Code 485.175, the Nevada Department of Motor Vehicles
(DMV) requires that all requests for driver records used for insurance purposes must contain an
insurance carrier’s National Association of Insurance Commissioners (NAIC) number. Agents/brokers
who request Nevada Motor Vehicle Reports (MVRs) are required to provide iiX with the NAIC number
of the insurance company where they intend to place the coverage.
iiX is not able to process Nevada MVRs without an appropriate NAIC number. For access to Nevada
MVRs, please complete and return this form to iiX.
Please return the completed form: By Fax: By Mail: IntelliCorp; 3000 Auburn Drive, Suite 410
Attn: MVR Compliance 216-450-5249 Beachwood, OH 44122
I
nsurance Information Exchange, a unit of ISO Claims Services, Inc. Created on 10/10/07
1716 Briarcrest, Suite 200 Bryan, TX 77802 Version IC NV 2007.1
