Data Privacy Request Form

Your privacy is very important to us. The CPRA (California Privacy Rights Act) provides California residents with specific rights regarding their personal information. You may use the web form below to submit a request to access or delete the personal information we have collected about you.

We will use the information you provide below to process and document your request as permitted by law.

* Mandatory fields

This request is for:
Are you a current employee?
*Please select the right(s) you would like to request:
Consumers have the right to request that a business not sell or share personal information to third parties.
Consumers have the right to provide affirmative authorization permitting the business to sell personal information about the consumer by a parent or guardian of a consumer less than 13 years of age or by a consumer who previously opted out of the sale of personal information.
Consumers have the right to request that a business disclose the specific pieces of information that it has collected about the consumer.
Consumers have the right to request that a business delete personal information that it has collected about the consumer.
*Please select all options below that describe your relationship with us:
An individual who has purchased a policy or someone who is covered under a policy.
An individual who acts on behalf of the provider to sell its policies.
A person asserting a claim against any person under a policy.

Consumer Information

Please enter first name
Please enter last name
Please enter street address
Please enter city
State
State is mandatory!
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Please enter zip code
Please enter phone number
Please enter date of birth

Download Forms

Declaration

Helpful Links

Data Privacy Request F A Qs