* Required Fields
What information do you need? Check all that apply. Access dataRemove data (right to erasure)Restrict data processing for specific purposesWithdraw consent from marketing communicationsCorrect or update dataObject to processingGet a digital copy of data (portability)Request information about whether my data has been sold in the last 12 monthsDo not sell my personal information
Data request information - What is your specific request? Do not include any sensitive personal information.
What is your relationship to INSURICA? Current customer Former customer Not a customer, but my employer is an INSURICA customer Current employee Former employee Other
Customer Number, if applicable
First Name
Last Name
Phone
Email
Address
City
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Europe Armed Forces Pacific Puerto Rico
Zip
Employer Name
Other Information - Enter any additional comments or relevant information. Do not include any sensitive personal information.
Comments
If you are unable to complete this form, please email your request to privacyofficer@insurica.com. For more information about our privacy policies, including our Privacy Notice for California Residents, click here.