PennDOT DL-9106 Insurance Affidavit Guide – Insurance companies and agencies operating in Pennsylvania that need access to driver records must complete and submit PennDOT Form DL-9106, officially titled the Insurance Company / Agency Affidavit of Intended Use. This notarized affidavit is required by the Pennsylvania Department of Transportation (PennDOT) Information Sales Unit to ensure that confidential driver information is requested and used only for legitimate insurance business purposes.
This guide provides current, accurate information for U.S.-based insurance professionals, agencies, and compliance officers. It covers the form’s purpose, step-by-step completion instructions, required attachments, notarization rules, and where to submit the completed document. Always download the latest official version directly from PennDOT to avoid outdated forms.
What Is PennDOT Form DL-9106?
Form DL-9106 is an official Pennsylvania Department of Transportation affidavit used exclusively by insurance companies and agencies. It certifies that the requester will use driver record information obtained from PennDOT solely for legitimate insurance-related activities, such as underwriting, claims handling, or policy administration.
The form falls under PennDOT’s Information Sales Unit processes and aligns with federal and state privacy protections, including the Driver’s Privacy Protection Act (DPPA). Completing this affidavit is a prerequisite for gaining authorized access to driver histories through approved information providers or PennDOT’s business access channels.
The current version of the form is DL-9106 (5-22). You can download the official PDF here: PennDOT Form DL-9106 PDF.
Who Needs to Complete Form DL-9106?
The following entities must file Form DL-9106:
- Licensed insurance companies writing motor vehicle liability policies in Pennsylvania
- Insurance agencies and brokerages that request driver records on behalf of insurers or clients
- Any insurance-related business seeking authorized access to PennDOT driver information for legitimate business purposes
Individuals requesting their own driving records do not use this form. Employers generally use a related form (DL-9105 – Employment Affidavit of Intended Use). Form DL-9106 is specific to the insurance industry.
Purpose of the Affidavit of Intended Use
PennDOT requires this affidavit to protect the confidentiality of driver records. By signing and notarizing DL-9106, the insurance company or agency formally agrees to:
- Use records only for legitimate insurance business
- Protect the confidentiality of the information
- Refrain from personal inquiries, selling, or redistributing the data
- Avoid using the information for direct mail advertising or unauthorized internet publication
- Maintain procedures that prevent misuse
False statements on the form are subject to penalties under 18 Pa.C.S. § 4903(a)(2) (false swearing), which can include fines up to $5,000 and imprisonment of up to two years.
How to Complete PennDOT Form DL-9106 – Step-by-Step Instructions?
Follow these official instructions carefully to avoid processing delays. Incomplete forms are returned.
- Business Type – Check one box: Individual, Partnership, Corporation, or Non-Profit.
- Legal Business Name and D/B/A – Enter the full legal name and any “Doing Business As” name.
- Person Responsible – Provide the name and title of the individual authorized to certify compliance. This person must also appear in the Ownership section.
- Contact Information – Complete physical address, city, state, ZIP code, business telephone, fax, email, and website.
- Federal Employer Identification Number (FEIN) – Enter the FEIN. If a corporation, also list the date and state of incorporation.
- Business Details – Provide the year the business was established, Dun & Bradstreet number (if available), and NAIC number (if applicable).
- Licensing Information – List Certificate of Insurance/Authority number, Agency or Brokerage License number, and Agent or Broker License number, including state and expiration dates for each. Attach copies of all insurance certificates and licenses.
- Location of Records – Indicate where records are kept for potential PennDOT audit. Check the box if the address is the same as the business address above.
- Ownership Section – List the name, title, phone number, and email of every individual, partner, or corporate officer who participates in the direction, control, or management of the business. Attach an additional sheet if needed.
- Account / Subaccount Information – Enter any existing account number. Indicate whether this is an update to an existing subaccount and provide the current subaccount number if applicable.
Use blue or black ink if completing by hand. Type or print clearly. Enter “N/A” for any field that does not apply.
Declaration Statements – Initial Each One
The authorized person must initial all eight declaration statements on the form. These affirmations cover proper use, confidentiality protections, prohibition on personal use, restrictions on selling or transferring data, ownership of records by PennDOT, ban on direct-mail advertising, restrictions on internet publication, and the truthfulness of the statements under penalty of law.
Notarization Requirements
The completed form must be signed and dated in the presence of a notary public (or other person authorized to administer oaths). The notary must complete the “Subscribed and Sworn to Before Me” section, including month, day, and year, and apply an official seal.
The signature date on the form must match the notarial date exactly. Digital signatures or remote notarization may not be accepted; original ink signatures and seals are typically required.
Where to Submit the Completed Form?
According to official instructions, the completed and notarized Form DL-9106 must be returned to your information provider (the vendor or service through which you access PennDOT driver records). The information provider then forwards the affidavit to PennDOT for approval.
Do not mail the form directly to PennDOT unless specifically instructed by your provider. Contact your information provider for the exact mailing address and any additional submission requirements.
When Must a New Affidavit Be Filed?
You are required to complete, notarize, and file a new Form DL-9106 whenever any of the following information about your company changes:
- Legal business name or D/B/A
- Physical address
- Ownership or officers
- Telephone number
- Website address
- Licensing information
Failure to update the affidavit can result in suspension of access to driver records.
Official Download Link for Form DL-9106
Always obtain the most current version of the form from the official Commonwealth of Pennsylvania website:
Download PennDOT Form DL-9106 (PDF)
For general driver and vehicle services information, visit the official PennDOT Driver and Vehicle Services site at pa.gov/agencies/dmv.
Additional Resources and Contact Information
If you need assistance completing the form, contact your designated information provider first. For broader PennDOT questions, call the Driver and Vehicle Services Customer Call Center at 717-412-5300 (Monday–Friday, 8 a.m. to 5 p.m. ET, excluding holidays).
Related official resources include:
Key Takeaways for Insurance Professionals
Form DL-9106 is a critical compliance document for any insurance company or agency that accesses Pennsylvania driver records. Accurate completion, proper notarization, attachment of current licenses, and timely updates when company information changes are essential to maintaining authorized access.
Download the official form today, complete it carefully, and submit it through your information provider to stay compliant with PennDOT requirements.