alaska request for crash report form pdf

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Form # 440 R ev 0 9 /202 3 STATE OF ALASKA Division of Motor Vehicles Request for Crash Report Form I am requesting the following: Crash Report Form 12 -200 completed by law enforcement Crash Report Form 12- 209 completed by myself *All motor vehicle records are subject to the Federal Driver Privacy Protection (Chapter 123, Section 2721) and considered confidential under Alaska law (AS 28.10.505). Personal information from these records may only be released to individuals or organizations that qualify under one of the exceptions listed on the back of this form. Crash Report/Incident # (if available) Date of Incident/Crash (required) Region o r Ci ty the Crash Occurred (optional) Name of Driver (required) I qual ify to obtain this information as part of my own personal record I qualify under exception number on the back of this form. Signature of R equestor Date Printed Requestor Na me Date o f B irth Alaska D river’s L icense N umber Government A gency or B usiness R equesting Contact Telephone # Email Mailing Address to Send Crash Report City State ZIP Code There is a $10 fee per crash report requested. Payment can be made by check or money order payable to the State of Alaska. Payment via VISA, MasterCard, or A merican Express is acceptable by provid ing your email address . A n invoice will be emailed and o nce payment has been made, we will mail your crash report to you. You can mail this form to: Division of Motor Vehicles; Attn: Driver Service s; 4001 Ingra Street, Ste 101; Anchorage, AK 99503 or email to doa.dmv.ads@ala sk a.gov . For any questions you may contact the DMV at 907-269-5551. My s ignature on this document acknowledges tha t I u nderstand that improper release of information and/or f alse representations to g ain information fr om DMV record a re pr ohibited a cts. Disclosure of Personal Information Contained in Motor Vehicle Records AS 28.10.505 The department may not disclose personal information notwithstanding AS 40.24.300 or unless excepted as provided in this section. Personal information means information that identifies a person, including a name, address, telephone number, and medical or disability information, but does not include information on vehicular accidents, driving - or equipment- related violations, driver ’s license or registration status, or a zip code. Permissible Uses : A. Motor vehicle or driver safety and theft B. Motor vehicle emissions C. Motor vehicle product alterations, recalls or advisories D. Performance monitoring of motor vehicles and dealers by motor vehicle manufacturers E. Removal of non- owner record from the original owner records of motor vehicle manufacturers as required by federal law. Exceptions : 1. By wr itten consent of person who is the subject of the information. 2. For u se by a government agency, including a court or law enforcement agency, in carrying out its functions or by a private person or entity acting on the behalf of a government agency in carrying out its functions. 3. For us e in the normal course of business by a legitimate business or an agent, employee, or contractor of the business, but only to: a. Verify the accuracy of personal information submitted by an individual b. To obtain correct information, but only for purposes of: • preventing fraud by the individual • pursuing legal remedies against • recovering on a debt or security interest against, an individual 4. For us e in connection with a civil, criminal, administrative, or arbitration proceeding in a court or government agency or before a self -regulatory or enforcement of a judgment or court order; 5. For use in research activities, or in producing statistical reports, if the personal information is not published, re-disclosed, or used to contact an individual; 6. For u se by an insurer or insurance support organization, or by a self -insured entity, or an agent, employee, or contractor of an insurer, in connection with claims investigation activities, anti -fraud activities, rating, or underwriting; 7. For us e by an employer or an agent or insurer of an employer to obtain or verify information relating to a holder of a commercial driver’s license that is required under 49 U.S.C. 31101 – 31162 (Commercial Motor Vehicle Safety Act); 8. For us e in connection with the operation of private toll transportation facilities; 9. For us e in connection with a legitimate business operating under a contract with the department; 10. For bu lk distribution for surveys, marketing, or solicitations if the person who is the subject of the information has provided written consent to the release; 11. For a ny other purpose specifically authorized by law that is related to the operation of a motor vehicle or related to public safety Form # 440 R ev 0 9 /202 3