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Edit Address Information

Company Name:	(Legal Business Name)
DBA:
Mailing Address:
Mailing Address:
City:		State:	Zip:

	Physical Address same as Mailing Address?
Business Location:	COMMERCIAL building or office RESIDENCE (home-based business)
Physical Address:
Physical Address:
City:		State:	Zip:

Phone:	Ext:	No Fax:	Fax #:
Alt Phone:	Ext:		Alt Fax #:

Prior Address:
Prior Address:
City:		State:	Zip:
Prior Phone:	Ext:
Prior Phone 2:	Ext:


DBA:
Address:
Address:
City:	State:	Zip:

Add Address

Indicates a required field.

Federal Identifier (FEIN):	(Federal Tax ID or SSN if Sole Proprietor)
Document Attached:	940 Form Federal Tax Return Business License State Sales and Use Tax Certificate Other Business Document
Business Type:	Sole Proprietor / Individual Partnership Corporation Non-Profit / Govt.
State of Incorporation:

Number of Employees:
Business Description:

Type of Business:

Insurance Agency
	Indicate Type(s):	Personal Lines Commercial Lines Life Insurance
Insurance Company
	AM Best #:
	NAIC Code:
	Indicate Type(s):	Personal Lines Commercial Lines Life Insurance
Other:

Type of Notices to Report:

Auto Policy Notices Home Policy Notices Escrow Invoices

No Website (URL) Address:
Company Website (URL) Address:	(ex. www.iix.com)

Main Contact First Name:
Main Contact Last Name:
Main Email Address:
Confirm Main Email Address:
Main Contact Phone:	Ext:

Send Invoice ATTN of First Name:
Send Invoice ATTN of Last Name:
Invoice Email Address:
Confirm Invoice Email Address:
Invoice Contact Phone:	Ext:

Please provide the name and email address of the individual who will be signing the Subscription Agreement. The Signing Party must be authorized to bind the business.

Signing Party Name:
Signing Party Email Address:
Confirm Signing Party Email Address:

Some customers may be asked to participate in a brief Onsite Visit. This portion may be entered to include an Onsite Visit contact, if it differs from the main contact on the account.

Onsite Visit Contact First Name:
Onsite Visit Contact Last Name:
Onsite Visit Email Address:
Confirm Onsite Visit Email Address:
Onsite Visit Contact Phone:	Ext:
Onsite Visit Contact Alt Phone:	Ext:

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Reason for Ordering Services:
(check all that apply)

Employment purposes (Current or Prospective Employees)

My business orders services for another reason:

Reason for Ordering Services:
(check all that apply)

My business orders reports for Underwriting purposes for these insurance line(s):

Personal Lines Commercial Lines Life Insurance

My business orders services for another reason:

Note

If more than one reason exists for your organization, please contact a Sales Representative at 800-683-8553, option 2.

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Decline Automatic Archive Search

Decline Decline Automatic DL Verify

Decline Automatic State Database Search - MO only (by declining, instant access to MO MVR's becomes unavailable, and next business day turn-around becomes standard for MO MVR requests.)

Decline Automatic State Database Search - OH only (by declining, instant access to OH MVR's becomes unavailable, and next business day turn-around becomes standard for OH MVR requests.)

The states below require additional forms to be filled out for MVR access. Please select the state forms that you need.

Select All \| Select None
Alaska	California	Colorado	Florida	Georgia	Indiana	Maryland	Nevada	New Hampshire	New Jersey
New Mexico	Ohio	Pennsylvania	Utah	Virginia	Washington	West Virginia

California

Access to state driving records requires the state's prior approval and requester code. A new authorization/release must be obtained from the consumer each time a record is ordered.

I do not have a California Requester Code

	California Requester ID:	include CALIFORNIA COMMERCIAL REQUESTER ACCOUNT APPROVAL from state with agreement.
To obtain the California Requester ID application, please visit the California page within the INFORMATION > FORMS section at www.iix.com. Your account can be updated to allow processing of California MVR's once you obtain the requester code.

Nevada

The state form does not expire. All requests for driver records for insurance purposes must have an insurance carrier's National Association of Insurance Commissioners ("NAIC") number.

New Hampshire

Employment: The state form expires annually. The form must be copied onto your company's letterhead.

Auto Insurance, Life Insurance: The state form expires annually. The form must be copied onto your company's letterhead. All requests for driver records for insurance purposes must have an insurance carrier's National Association of Insurance Commissioners ("NAIC") number.

Life Insurance Form:

Pennsylvania

The state form does not expire. The original form must be mailed; it MAY NOT be returned to iiX via fax. Once received, it is sent to PENNDOT for approval and assignment of a sub account number. Once iiX receives this, access to state records is permitted. Any time the company's information changes (name, address, ownership, telephone, website, etc.), the company must send iiX a new, notarized Affidavit of Intended Use.

Person Responsible:		Title:
Date of Incorporation:		Year Business Est.:
Dun & Bradstreet #:		U.S. DOT #:	(if applicable)

Licensing Information (list & attach copy with affidavit)
Cert. of insurance/Authority #:		State:		Expires:
Agency or Brokerage License #:		State:		Expires:
Agent or Broker License #:		State:		Expires:

Location of Records (For departmental on-site inspection, audit, and review purposes)
	Location of Records same as Physical Address?
Street Address:
City:		State:		Zip:
Type of Business:

Utah

To obtain Utah driving records through iiX, customers must register their organizations with Utah.gov. Instructions will be provided with forms.

Washington

Is this company an employer, prospective employer, or volunteer organization of the individual whose driving record is being requested? Yes No
Is the record you are requesting necessary for employment purposes related to driving by the employee or prospective employee as a condition of employment or related to driving by the volunteer at the direction of the volunteer organization? Yes No
Do you agree to use the information contained in the record exclusively for this purpose and not divulge it to a third party? Yes No
Do you agree to hold harmless the Washington State Department of Licensing for all matters relating to the release of the requested driving record? Yes No

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