Information Access Request

Please fill out the form below to submit your information access request. We will acknowledge receipt of your request within 10 days. However, full processing of your request may take up to 45 days from the date of submission. Your request may be subject to verification of your identity prior to completion. You may also submit your request by calling 866.423.1818 and speaking with our Consumer Privacy Coordinator.

Consumer Name *

First

Last

Would you like to enter a physical address for this person? *

Consumer Current Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

IMPORTANT: Our company does not possess any information on persons who reside outside the United States. Your request must pertain to a U.S. address only.

Would you like to enter a second physical address for this person? *

Consumer Second Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

IMPORTANT: Our company does not possess any information on persons who reside outside the United States. Your request must pertain to a U.S. address only.

Would you like to enter a third physical address for this person? *

Consumer Third Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

IMPORTANT: Our company does not possess any information on persons who reside outside the United States. Your request must pertain to a U.S. address only.

Would you like to enter a fourth physical address for this person? *

Consumer Fourth Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

IMPORTANT: Our company does not possess any information on persons who reside outside the United States. Your request must pertain to a U.S. address only.

Consumer Primary Email Address *

Confirm Email

Would you like to enter a second email address for this person? *

Consumer Second Email Address *

Confirm Email

Would you like to enter a third email address for this person? *

Consumer Third Email Address *

Confirm Email

Would you like to enter a fourth email address for this person? *

Consumer Fourth Email Address *

Confirm Email

Would you like to enter a phone number for this person? *

Consumer Phone Number

Would you like to enter a second phone number for this person? *

Consumer Second Phone Number *

Would you like to enter a third phone number for this person? *

Consumer Third Phone Number *

Would you like to enter a fourth phone number for this person? *

Consumer Fourth Phone Number *

The person submitting this privacy request is *

Consumer Advisory

You will receive an email acknowledging receipt of your request within 10 days of submission. We may take up to 45 days to fully process your request. We may need to contact you directly to validate your identity before your privacy request can be fully processed.

Authorized Agent Advisory

Authorized Agents acting on behalf of a consumer must complete all information below and upload the document granting authority to act on the consumer's behalf. Incomplete requests will not be processed. We reserve the right to contact the consumer directly to verify the authority of your agency.

The Authorized Agent is

Authorized Agent - Individual Name *

First

Last

Authorized Agent Company Name *

Enter the company name of the Authorized Agent.

Authorized Agent Company Contact Name *

First

Last

Authorized Agent Email Address *

Confirm Email

Authorized Agent Physical Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Authorized Agent Telephone Number *

Authorized Agent Website URL

Authorized Agent - Legal Basis for Agency *

Select the type of document that authorizes the Authorized Agent to act on this consumer's behalf.

Authorized Agent - Upload Agency Document *

Click or drag a file to this area to upload.

Use this box to upload the signed document (Power of Attorney, Agency Agreement etc.) in which the Consumer granted the Authorized Agent authority to act on his/her behalf. Failure to include evidence of authorization will result in the request being denied. Note: maximum file size is 256MB.

Authorized Agent - Certification & Consent to Electronic Signature

By my signature below, I, the undersigned, hereby certify under penalty of perjury that (a) the Authorized Agent designated above in fact has valid and legally sufficient written authority to submit this privacy request on behalf of the individual consumer named above and (b) I have in fact uploaded a true and correct copy of that document as part of this submission. I further consent to the use of electronic signatures in this Certification and submission and understand, agree, and intend that my electronic signature below is and shall be the legal equivalent of my manual handwritten signature for purposes of the Certifcation and submission made herein.

Authorized Agent By: *

First

Last

Entry of your name constitutes a valid, legally binding, signature as if signed manually/handwritten.