California Consumer Privacy Act Form

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California Privacy Rights Form

As a resident of California, you have certain rights to request know, access, correct, and delete Personal Information we may have about you or your household.

Please complete the following form and click Submit.

We will contact you if more information is required to satisfy your request.

If you are making a request as an authorized agent on behalf of someone else, additional documentation will be required.

Contact Us

California Privacy Rights Form

As a resident of California, you have certain rights to request know, access, correct, and delete Personal Information we may have about you or your household. You may also opt-out of the sale or sharing of your Personal Information for certain targeted advertising purposes and request we limit our use of your Sensitive Personal Information in certain circumstances.

Please complete the following form and click Submit.

We will contact you if more information is required to satisfy your request.

If you are making a request as an authorized agent on behalf of someone else, additional documentation will be required.

Relationship

What type of product(s) do/did you have? If more than one, please select one and add additional in the comments field.

Account/Policy/Plan Number (Optional)

Comments

Please supply the following information for the owner/insured/participant/account holder

First name

Middle name (optional)

Last Name

Social security number

Date of birth

Mailing Address

City

Zip code

Please supply your contact information

First name

Middle name (optional)

Last Name

Please supply your contact information

First name

Middle name (optional)

Last Name

Mailing address

City

Zip code

Email address

Re-enter email address

Phone number

NPN

Business/firm name or service provider

Email address

Re-enter email address

Phone number