Select an appropriate option for requesting disclosure by clicking the radio button provided for each option in the list. You are required to select one (1) of the seven (7) options.
Click button '1' if you applied for insurance and were denied coverage or assessed a premium due to an investigation that transpired as a result of the member insurance company receiving an MIB code(s); After clicking “Next,” click on “disclosure form” to print out the form that you must complete, sign, and send to MIB along with the letter you received from the insurance company. Upon receipt of these documents, MIB will process your disclosure request.
Click button '2' if you applied for insurance and the member insurance company informed you that they received an MIB code that they have been unable to verify so they asked you to obtain disclosure of your MIB Consumer File and send it to them in order to confirm that the code(s) belong to you.
Click button '3' if you are submitting a disclosure request on behalf of another individual under Power of Attorney as the individual’s attorney in fact; After clicking “Next,” click on “disclosure form” to print out the form that you must complete, sign, and send to MIB with the signed Power of Attorney. Upon receipt of these documents, MIB will process your disclosure request.
Click button '4' if you are submitting a disclosure request for someone else as his or her Legal Guardian or conservator; After clicking “Next,” click on “disclosure form” to print out the form that you must complete, sign, and send to MIB with a copy of the court appointment as guardian or conservator or other documentary evidence of such appointment. Upon receipt of these documents, MIB will process your disclosure request.
Click button '5' if the disclosure request is made by a parent on behalf of a minor child under the age of 18; After clicking “Next,” click on “disclosure form” to print out the form that you must complete, sign, and send to MIB. Upon receipt of this document, MIB will process your disclosure request.
Click button '6' if you are requesting free annual disclosure for yourself and you reside in the United States or Canada and none of the other choices apply.
Click button '7' if you are requesting free annual disclosure for yourself but you reside in a foreign country outside the U.S. or Canada. After clicking “Next,” click on “disclosure form” to print out the form that you must complete, sign, and send to MIB. Upon receipt of this document, MIB will process your disclosure request.