1. GEICO General Insurance Company
GEICO
geico.com
Government Employees Insurance Company
GEICO Indemnity Company
MN
GEICO Casualty Company
Telephone: 800-841-3000
Hawaii Juvenile Information Release Form
Please read, complete, sign and return this form to us for the young driver in your household under
age 21. If there are any other young drivers in your household under age 21, please contact us at
1-800-841-3000 to obtain a separate form(s). We request this form to be returned to us within 10
days, in the enclosed envelope or to the Fax number below.
DATE: __________________________________________
NAME OF MINOR: ____________________________________________________________________
DRIVER LICENSE OR PERMIT NUMBER: __________________________________________________
DATE OF BIRTH: _________________________________
I hereby authorize release of juvenile traffic information (abstract) for the above mentioned person to the following
companies at the address below:
Government Employees Insurance Company
GEICO Indemnity Company
GEICO Casualty Company
One GEICO West Cycle-Gard
PO Box 509090 One GEICO Landing
San Diego, CA 92150-9090 Virginia Beach, VA 23454
Fax: 808-593-0008 Fax: 305-503-7183
f f f
I understand that pursuant to , 92F-13(1), , 92F-13(4) and , 571-84(a) of the Hawaii Revised Statutes,
juvenile records are not subject to public disclosure.
________________________________________
Relationship to minor: __________________________
Signature of Parent or Guardian if under 18
________________________________________ Retention No: ___________________
Signature of Juvenile/Person
*M240HI*
M-240HI(08-09)
FOR OFFICE USE ONLY: Policyholder Name=Daniel Serrao Policy Number=4246915997
