Form Cd 3 – Fill Out and Use This PDF

MIB, Inc.

50 Braintree Hill Park – Suite 400

Braintree, MA 02184-8734

(781)751-6007; (781) 751-6104 (fax) infoline@mib.com

REQUEST FOR DISCLOSURE OF MIB CONSUMER FILE

Please print or type all information.

This form is only intended for use in providing disclosure to: (i) individuals who have received an adverse underwriting action letter or notice from an insurance company (see Section I); (ii) authorized legal representatives for consumers; and (iii) consumers residing outside the U.S. and Canada. Consumers residing in the U.S. and Canada should request their free annual disclosure using MIB’s toll free line (866-692-6901) or online facility (www.mib.com) (collectively, the “Streamlined Processes”). Because a consumer’s request for free annual disclosure is supposed to be submitted via the Streamlined Processes only, MIB reserves the right to decline a consumer’s request for free annual disclosure that is made using this form. In such an event, MIB may instruct the consumer to use MIB’s Streamlined Processes. Alternatively, MIB may also process a consumer’s request for free annual disclosure using this form if the consumer declines to use MIB’s Streamlined Processes, but agrees to pay the fee that is allowed by law.

To learn more about the personal information we collect, use and disclose in the conduct of our business, please refer to MIB’s Consumer Privacy Policy at: https://www.mib.com/privacy_policy.html.

SECTION I – Identify Whether Disclosure Request Follows an Adverse Underwriting Action

Are you requesting disclosure because you applied for insurance but your application was denied or you were charged an extra premium (either of which is an “adverse underwriting action”) and the insurance company indicated that MIB provided information that influenced its underwriting investigation?

If you answered “yes,” then you must submit a copy of the adverse underwriting action letter (or notice) from the insurance company along with this Request for Disclosure form in order to obtain certain benefits you are entitled to under the federal Fair Credit Reporting Act.

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Last Name (surname)First Name (given name)Middle Initial or Name

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Current Address Street, PO Box, or RFD	City or Town	State	Zip Code
___________________________________	____________________________		______________________________________
Area Code/Telephone No	Date of Birth (mo/day/year)		Occupation
__________________________________________		__________________________________________		____________________________________
Place of Birth (If U.S., give state; if Canada, give province; otherwise, give country).		Social Security Number		Email address

SECTION III - Supplemental Information – Other Names Used By Consumer

Please list all other names (given names and surnames) and variations of names (different combinations of initials and given names such as John H. Doe, J.H. Doe and J, Harrison Doe) that you would have given an insurance company within the past seven years. This additional information will assist MIB and/or the reporting company in identifying a record, if any, should there be other records with similar identifiers.

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Last Name (surname) First Name (given name)Mid. In.

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Last Name (surname)	First Name (given name)	Mid. In.

SECTION IV – Other Address Information For Consumer:

If you have been at your current residence for less than two years, please provide your prior residence address. Please state house or apartment number, followed by the street name, city, state/province, zip/postal code. If none, state “None”.

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Previous Address Street, PO Box, or RFD

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City or TownStateZip Code

SECTION V – Acknowledgement and Certification of Person Requesting Disclosure:

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Date Signed	By signing, I certify that: (1) I am the individual identified in Section II or an authorized legal representative for such individual
	(parent of minor, guardian, attorney-in-fact under POA); and (2) the information provided above (and any documentation
	accompanying this request) is true and accurate. I acknowledge that MIB will need to verify my identity by using a service
	provided by a third party that has personal information about me.
	If signing as a legal representative, state your capacity and, as appropriate, provide evidence of your authority (appointment or
	Power of Attorney). Disclosure is not provided to estate representatives and surviving relatives for deceased consumers.

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Current Address Street, PO Box, or RFD; City, State and Zip Code for authorized legal representative above	Area Code/Telephone No
Form CD-3, Revised 03/26/2020