MVR Consent Form

"*" indicates required fields

It is understood that my employment requires (or may require) me to drive either a company, owned vehicle or my own vehicle on company business. I understand that my employer and/or the insurance company writing my employer’s insurance requires my driver’s license number and information in order to assess my insurability by running a Motor Vehicle Record(MVR) report. I also understand that I have the right to see a copy of my MVR upon request.

By this letter, I hereby authorize my employer and/or the insurance company and/or Heffernan Insurance Brokers to obtain the necessary motor vehicle records and authorize them to send a copy of my Motor Vehicle Record to my employer.

This authorization will be valid until such time I leave my employer.

Date of Birth*
MM slash DD slash YYYY