Thank you for logging your response with us. Once we have reviewed your request we will send you an email with your case number to the email address you have provided. Your reference number for this request is displayed below.

CCPA Intake Form - Test

Privacy Rights Request Form

This Privacy Rights Request Form is intended to facilitate the exercise of certain rights granted under the California Consumer Privacy Act (CCPA).

Your Right to Know:

You have a right to know what Personal Information Categories we have collected, used, disclosed or sold about you in the previous 12 months and the purposes of such actions. You have a right to know the sources of collection of such information and to whom we have disclosed it to for business purposes or a sale. You also have a right receive a list of the Personal Information we have collected about you in the last 12 months from the date of your request.

Your Right to Delete:

You have a right to instruct us to delete certain Personal Information we hold about you. We will assess your request and determine, under the CCPA, what Personal Information we are required to delete.

Please Select Your Choices:

Exercise Your Right to Access Your Information: You may request this information up to two times in a 12 month period

Exercise Your Right to Delete Your Information

Consumer Information

Please include name and information for one consumer only. If any additional consumers are applicable, please fill out a separate form.

Account Information

If the consumer is an owner, please enter either the member number and/or contract number.

Please enter a valid member number.
Please enter a valid contract number.
Please select this if you are an Authorized Agent for the consumer. If no continue to bottom of page to "Submit" your request.

CCPA Authorized Agent

Authorized Agent Information

If you have checked that you are an Authorized Agent, you must fill in section below.

For Authorized Agents Only:

If you are submitting this on behalf of another person as an Authorized Agent of such person, please send proof of your Agent relationship to [email protected] Note: The request may not be processed until proof of agency is received. (See privacy notice for details)