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Coverage INCORPORATED THE INSURANCE SPECIALISTS 4460-P Brookfield Corporate Drive, Chantilly, VA 20151 * Office: (703) 631-8000 * Fax: (703) 631-8224 www.coverageinc.com AUTHORIZATION TO OBTAIN MOTOR VEHICLE RECORD Fax to: 703-631-8000 VA Code 46.2-208 classifies driver abstracts as privileged records and limits the release of an abstract of a driver’s record to only an employer, potential employer, or authorized agent who has been authorized in writing by such driver to obtain the driver’s record. THE UNDERSIGNED DOES HEREBY ACKNOWLEDGE AND CERTIFY AS FOLLOWS: 1. That the undersigned gives his or her consent to the release of their driving record (“MVR”)for review by Name of Employer or Potential Employer: 2. That the undersigned authorizes his or her driving record to be periodically obtained and reviewed for the purpose of initial and continued employment. 3. That the undersigned gives his or her consent to the release of their driving record (“MVR”) for review by Name of Agency: Coverage, Inc. 4. That the undersigned understands that his or her driving record may also be provided to insurance carriers for the purpose of determining the insurability of certain hazards. Name of employee/potential employee: ________________________________________________ (Print full name as it appears on your license) License Number & State: ___________________________________________________________ Date of Birth: _____________________________________________________________________ Signature of employee/potential employee: _______________________________________________ Date:___________________________________________________________________________ |
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