Motor Vehicle Record Review Consent Form


I grant Sanfilippo & Sons Insurance the right to review my motor vehicle driving record at anytime. Additionally, I understand that I am required to maintain a valid drivers license. In accordance with the Insurance Company's MVR review program, a review of my motor vehicle record may result in my status being listed as a non-driver for a year pending the next annual review.

Driver Information
First Name
Required
Last Name
Required
Date of Birth
Required
/ /
License State
Required
License Number
Required
Does this driver have any major violations or claims in the last five years?
Optional
ZIP / Postal Code
Required
E-Mail Address
Required
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.