Request for Disclosure and Invoice Forms (U.S.) Please complete the Invoice Form, complete and sign the Request for Disclosure Form (D-2), and send them to MIB at the following address: MIB, Inc. P.O. Box 105 Essex Station Boston, MA 02112 The charge for record search and disclosure is $8.00, which may be paid by check, money order or credit card as indicated on the Invoice Form. The fee for record search and disclosure is non-refundable. INVOICE AMOUNT ENCLOSED: $ TYPE OF PAYMENT: Master Card Visa Check/Money Order (Complete information below if Type of Payment is either Master Card or Visa) CARD NUMBER: 8888 8888 8888 8888 EXP. DATE __ /__ MM YY NAME AS IT APPEARS ON CARD (Please print): SIGNATURE (Card Owner or Authorized User) CIRCUMSTANCES UNDER WHICH THERE MAY BE NO CHARGE FOR RECORD SEARCH AND DISCLOSURE You may be entitled to record search and disclosure at no charge if, within sixty (60) days prior to your Request for Disclosure, both of the following conditions are met: Your application for Life, Health, or Disability insurance was declined or you were charged an extra premium (hereafter referred to as “adverse action”) and, the insurance company which took the adverse action provided you with a Notification which identified MIB as an information source. To qualify for Disclosure without charge, you must attach a copy of the Notification in place of payment. You may also be entitled to one MIB record search and disclosure at no charge every 12 months upon request if you can certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your MIB record is inaccurate due to fraud. MIB will, upon request, advise you as to the certification process. MIB reserves the right to verify requests for free disclosure. PROCESS FOR SEARCHING FOR MIB RECORDS Upon receipt of a properly completed Request for Disclosure (Form D-2) and accompanying payment, MIB will initiate a record search process under your name as follows: 1. A record search will be conducted of the MIB database, the Disability Insurance Record System (DIRS) database, and the Health Claims Index (HCI) database for records of coded reports, if any, as of the date of the search. MIB records are retained for seven (7) years from receipt, DIRS reports are retained for five (5) years, and HCI reports for seven (7) years; 2. A similar record search will be conducted of the Insurance Activity Index (IAI) for inquiries made, if any, by MIB member insurance companies in the past two (2) years; 3. Similar record searches will be conducted of the MIB, DIRS, HCI, and IAI databases for the names of any member insurance companies that received copies of reports from MIB in the past twelve (12) months. MIB, Inc. (MEDICAL INFORMATION BUREAU) P.O. Box 105, Essex Station - Boston, MA 02112 - (617) 426-3660 REQUEST FOR DISCLOSURE OF MIB RECORD INFORMATION FOR RESIDENTS OF THE UNITED STATES OF AMERICA See instructions on next page. Please print or type all information. WARNING: IT IS ILLEGAL TO OBTAIN INFORMATION UNDER FALSE PRETENSES. 15 U.S.C. 1681q (Fair Credit Reporting Act) provides: “Any person who knowingly and willfully obtains information on a consumer from a consumer reporting agency under false pretenses shall be fined not more than $5,000 or imprisoned not more than one year, or both.” Section I - Name, Address, and Telephone: Mr. Mrs. Ms. Other: Name 8888888888888888888888888 8888 8888 888 8 Last Name (surname) 888888888888888888 Area Code/Telephone No.(optional) First Name (given name) Middle Initial Current Address 88888888888888888888888888888888888888 88888888888888888 8888 888888888888 Street, P.O. Box, or RFD City or Town State Zip Code Section II - Primary Identification Information: 88 88 88 Date of Birth (mo./dy./yr.) 88888888888888888 Place of Birth (If U.S., give state; if Canada, give 888 88 8888 Social Security Number (optional) province; otherwise, give country) 8888888888888888888888888 Section III - Supplemental Identification Information (see instructions on next page): Other names used 888888888888888888 8 Last Name (surname) 8888888888888888888888888 First Name (given name) Middle Initial Other names used 888888888888888888 8 Last Name (surname) First Name (given name) Middle Initial Section IV - Method of Disclosure of MIB Record Information: I request disclosure by the following method (check one): A. By letter to my address as given above. B. By reverse charge telephone call at my telephone number as given above (see instructions on next page). C. In person by appointment (see instructions on next page). Date and Hour in Eastern Time Section V - Request for Disclosure and Certification: I request disclosure of the nature and substance of my MIB record, if any, in accordance with my instructions as given above. I certify that I am the individual described in Section I, II, & III, or the parent or legal guardian of said individual, and that the above information described is true and accurate. Date Signed Signature of individual requesting disclosure; if not the same as individual described in Section I, state capacity in which you are signing, such as parent or legal guardian. Please include completed invoice form and payment and mail to the address shown at the top of this page. Form D-2, Revised 01/03/98 REQUEST FOR DISCLOSURE OF MIB RECORD INFORMATION GENERAL INFORMATION Upon request and proper identification, you are entitled to receive: 1. The nature and substance of any information that MIB may have in its files pertaining to you; 2. The name(s) of the MIB member companies that reported information to MIB; and, 3. The name(s) of the MIB member companies that received a copy of your MIB record(s) during the twelve (12) month period preceding your request for disclosure. Disclosure will be made within 30 days of receipt of your completed Request for Disclosure (Form D-2) at the MIB Information Office, barring unusual circumstances. Disclosure will be made directly to you. In some cases, it may be necessary to disclose medical information to a licensed medical professional. In such cases, MIB will ask you for the name and address of a licensed medical professional to whom disclosure will be made. Occasionally, MIB may need additional identification information to determine if you have a record. This information might include spouse’s name, occupation, or other insurance companies to which you applied. In such cases, MIB will ask you to provide additional information. Should you need to contact MIB by phone, please be advised that MIB has installed a voice mail system. Please leave your message as instructed. A representative will contact you, promptly. Your cooperation is appreciated. INSTRUCTIONS Section I Furnish all information requested. The telephone number provided should be one where you can be contacted Monday through Friday (except Massachusetts holidays) between the hours of 10:00 a.m. and 4:00 p.m., Eastern Time Zone. Section II Furnish all information requested. MIB needs date and place of birth to determine if you have a record. Section III List any other names or variations of your name that you have given to any insurance company within the past seven years, such as maiden name, or the use of different combinations of initials and given names (e.g., J. H. Smith or J. Harrison Smith). This additional information will assist MIB and/or the reporting company in identifying your record, if any, should there be other records with similar identifiers. Section IV Indicate preferred method of disclosure by checking Box A, B, or C. If you check Box B, disclosure will be made to you at the telephone number provided in Section I. Insert a date which is no earlier than 30 days after you mail this form and indicate a time, between the hours of 10:00 a.m. and 4:00 p.m. Eastern Time Zone, any weekday (except Massachusetts holidays). If you check Box C, an MIB representative will contact you at the telephone number provided in Section I to schedule the date and time of appointment. Appointments will be scheduled no earlier than 30 days after receipt of this form. If no box is checked, disclosure will be made by mail to the address provided in Section I. Section V Date, sign, and return to the MIB Information Office at the mailing address listed on the letterhead. Unsigned Requests for Disclosure will be returned.