COLORADO STATE FORM INSTRUCTIONS
The following information will assist you in completing the appropriate form to access
MVRs in this state.
• Note: This form is for employment purposes only.
• Fill in all blanks in account information fields completely.
• Be sure to include your Insurance Information Exchange Account Number.
• Sign and date the forms in the fields provided.
• Do not complete shaded area at bottom of page 1 titled:
Information Below is intended…
• On page 2 & 3 include iiX account number; fill in company’s name in first blank
line provided. Sign and date page 3.
• Only a person who is authorized to execute contracts for your company should
complete and sign this form.
• State form expires on an annual basis.
• Mail or fax signed form to:
Insurance Information Exchange
Attn: Compliance Department
3011 Earl Rudder Freeway S.
College Station, TX 77845
Fax No. (979) 693-2907 or (201) 748-1019
1. COMPLETE & SIGN TO RECEIVE COLORADO DRIVER RECORD INFORMATION.
2. FAX COMPLETED FORM TO: iiX
ATTN: COMPLIANCE DEPT. (State form expires on an annual basis)
AFFIDAVIT OF INTENDED USE AND REQUESTOR RELEASE
To obtain record(s), you must declare your intended use of record(s). If you are acting as an agent for an
authorized user, you must identify the company or entity on whose behalf you are requesting the record(s).
INFORMATION MAY BE USED ONLY FOR THE FOLLOWING APPROVED PURPOSES:
By a government agency, including any court or law enforcement agency performing its functions for an
approved purpose under DPPA.
By an agency charged with driver/motor vehicle safety or theft including: MV product alterations, recalls,
advisories, MV performance monitoring, MV parts/dealers, MV market research or surveys, remo