Icd 072 Form PDF Details

In today’s digital age, processes and forms that facilitate seamless operations within governmental departments are essential for maintaining efficiency and compliance. The ICD-072 form, managed by the Motor Vehicle Administration (MVA) located at 6601 Ritchie Highway in Glen Burnie, Maryland, represents a pivotal component within this bureaucratic ecosystem, particularly for those in the insurance industry. Introduced to streamline the process by which insurance agents and companies request remote access to issue Maryland Insurance Certifications (Form FR-19), this document outlines a comprehensive procedure starting from the initial request to granting the necessary permissions for electronic reporting to the Insurance Compliance Division. Establishing a meticulous framework, the form delineates requirements for the requester such as completing the top section, obtaining necessary approvals, and acknowledging the responsibility that accompanies remote access privileges, including maintaining confidentiality and ensuring virus protection measures are in place. Furthermore, the form serves as a gateway, requiring signatories from the insurance company or agency officers and the MVA ACIS Business Administrator, thereby ensuring a multi-tiered scrutiny and approval process. It underscores the importance of such protocols in safeguarding sensitive data and maintaining the integrity of the Maryland Department of Transportation’s operational standards, as well as adhering to broader state and federal regulatory requirements.

Form NameIcd 072 Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesfr 19 form pdf maryland, fr19, fr 19 form, fr 19 form maryland

Form Preview Example

Motor Vehicle Administration

6601 Ritchie Highway, N.E.

Glen Burnie, Maryland 21062

ICD-072 (10-14)

MD MVA eFR-19 Remote Access Request Form


Complete top section of form, listing each “Insurer” company you are authorized to issue Maryland Insurance Certifications (Form FR-19),

“SignDate” sign, and date. This request may require approval from your Insurance Company or Agency Officer. Mail to ICD Business

Administrator at MVA Room 140, 6601 Ritchie Hwy, Glen Burnie, MD 21062, for authorization signature. ICD Business Administrator

will submit signed form to MVA Security Officer for verification of access type(s).



ACTION: New Request Account Change

Account Deletion

Add Insurer Association Remove Insurer Association

USERID: ____________________________

Producer License No issued by MD Ins Admin ______________________________

(assigned by MVA)





MD Insurance Agent: ___________________________________________________________

Phone: ( ) ____________________






Ins Co / Agency Name: ______________________________________ Address:______________________________________________


Agency Phone Number: ( )______________________________ Agency Fax Number: ( )______________________________

EMail Address:______________________________________________________________________________

Insurer’s Agent is Authorized to Issue Maryland Insurance Certifications (form FR-19) for: (use additional sheet if more than 6 insurers)

Insurer NAIC Code is the 5 Digit Number assigned by the National Association of Insurance Commissioners

Insurer NAIC

Insurer Name

Insurer NAIC

Insurer Name


Purpose of Remote Access:  To report Maryland Insurance Certifications Forms FR-19 electronically to Insurance Compliance Division.

ACKNOWLEDGMENT: Remote Access to the MDOT/MVA network is a privilege. I hereby acknowledge that remote access is authorized for my use only and that all passwords and user names are to be kept confidential at all times. By requesting a remote access account, I acknowledge that I will install or already have installed virus protection software on my remote (this includes business, home or laptop) system. In addition, I authorize MVA and/or their contractor to test the security of my connection to the MVA network by performing a coordinated vulnerability assessment when needed of my connection to the MVA network. Installation of the virus protection and applying virus signature updates is my responsibility. I understand that failure to do so may result in loss of remote access privileges. MVA employees are not responsible for any operating system, hardware or software application problems encountered by any MVA Remote Access User when using the designated applications to connect to the MVA

network. I have signed the MDOT Security Advisory agreement and I am aware of terms and conditions of the agreement.

Requester Signature/Date:  _____________________________________________________________________________


INSURANCE CO/AGENCY OFFICER: I authorize the requestor to be granted access to the MD ACIS eFR-19 Internet application.

ON BEHALF OF INSURANCE COMPANY AGENCY _______________________________________________________________

INSURANCE CO/AGENCY OFFICER Name & Title (Please Print): ______________________________________________________

INSURANCE CO/AGENCY OFFICER Signature/Date:   ________________________________________________________________


MD MVA ACIS BUSINESS ADMINISTRATOR: I authorize the requestor to be granted access to the ACIS eFR-19 internet application.

MVA ACIS Business Administrator Name (Please Print):_________________________________________________________________

MVA ACIS Business Administrator Signature/Date:   ____________________________________________________________________



MVA Security Officer Signature/Date:     __________________________________________________________________

For more information, please call: 410-768-7000 (to speak with a customer agent).

TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov

American LegalNet, Inc.





This ADVISORY is initiated for INFORMATIONAL purposes only. The following paragraphs shall in no way be construed as a waiver by the undersigned of the rights and protections provided by COMAR (Code of Maryland Regulations) Title 11, Department of Transportation, Subtitle 2, Transportation Service Human Resources System, if applicable, and/or by law or regulation.

The Office of Information Resources, its client agencies and their customers adhere to State data processing security policies as set forth in Executive Order 01.01.1983.18 (Privacy and State Data system Security); MD Code Ann., Criminal Law Article, §§ 8-606 (Making false entries in public records and related crimes) and 7-302 (Unauthorized access to computers and related material); MD Code Ann., General Provision Article, Title 4 (Maryland Public Information Act); MD Code Ann., Transportation Article, §§12-111 through 12-113 (Motor Vehicle Administration Records); and, as published by the Secretary of the Department of Budget and Management from time to time under MD Code Ann., State Finance and Procurement Article, Title 3A, Subtitle 3 (Information Processing).

Federal laws affecting access to and use of computer information include, but are not limited to, the following: 15 U.S.C. § 271 et seq. (National Institute of Standards and Technology); 44 U.S.C. § 3541 et seq. (Federal Information Security Management Act of 2002); 49 U.S.C. § 30301 et seq. (National Driver Register Act of 1982); 5 U.S.C. § 552 (Freedom of Information Act); 5 U.S.C. § 552a (Privacy Act of 1974); 18 U.S.C. § 1001 et seq. (Computer Fraud and Abuse Act of 1986); 17 U.S.C. § 109 (Computer Software Rental Amendments Act of 1990); 15 U.S.C. § 1681 et seq. (Fair Credit Reporting Act); 18 U.S.C. § 1030 (Computer Crime Statute of 1984); 18 U.S.C. § 2721 et seq. (Driver’s Privacy Protection Act of 1994); and Federal Copyright Law.

Specifically PROHIBITED ACTS include, but are not limited to:

1. Unauthorized access to or use of a computer, data or software.

2. Unauthorized copying or disclosure of data or software.

3. Obtaining unauthorized confidential information.

4. Unauthorized modification or altering of data or software.

5. Introduction of false information (public records).

6. Disruption or interruption of the operation of a computer.

7. Disruption of government operations or public services.

8. Denying services to authorized users.

9. Taking or destroying data or software.

10. Creating/altering a financial instrument or fund transfer.

11. Misusing or disclosing passwords.

12. Breaching a computer security system.

13. Damaging, altering, taking or destroying computer equipment or supplies.

14. Devising or executing a scheme to defraud.

15. Obtaining or controlling money, property, or services by false pretenses.

Authorized access to, including INTERNET and INTRANET, and use of information and computer resources is limited to the PURPOSE for which these privileges are granted. All authorized users during the term of their access and thereafter, shall hold in strictest confidence and not willfully disclose to any person, firm or corporation without the express authorization of the Director, OIR, any information related to security, operations, techniques, procedures or any other security matters. Any breach of security will be promptly reported to the Director, Office of Information Resources, designee or security officer.

I acknowledge that I have read and understand the foregoing security advisory.



Name: _____________________________________________



(Please print or type)






Apply to...Apply to register to vote with your driver’s license transaction. For details ask your customer service representative.

to Vote Now!

American LegalNet, Inc.


How to Edit Icd 072 Form Online for Free

Our top computer programmers worked hard to create the PDF editor we are pleased to deliver to you. This application permits you to quickly create fr 19 form and can save valuable time. You simply need to adhere to this particular guide.

Step 1: On this website page, select the orange "Get form now" button.

Step 2: After you have entered the fr 19 form editing page you'll be able to see every one of the options you may undertake about your document from the upper menu.

To prepare the template, enter the information the application will require you to for each of the following parts:

filling out fr 19 form pdf maryland part 1

You have to fill in the Purpose of Remote Access To, Requester SignatureDate, INSURANCE COAGENCY OFFICER Name, INSURANCE COAGENCY OFFICER, MVA ACIS Business Administrator, MVA Security Officer SignatureDate, For more information please call, and American LegalNet Inc space with the requested particulars.

part 2 to finishing fr 19 form pdf maryland

Inside the section talking about I acknowledge that I have read and, Date, Signature, Name, Please print or type, Apply to, Apply to register to vote with, to Vote Now, and American LegalNet Inc, one should jot down some required information.

step 3 to filling out fr 19 form pdf maryland

Step 3: Choose the "Done" button. Next, you can transfer the PDF file - save it to your device or deliver it through email.

Step 4: You can also make copies of the file torefrain from any upcoming issues. Don't worry, we don't display or track your information.

Watch Icd 072 Form Video Instruction

Please rate Icd 072 Form

1 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .