California Consumer Privacy Act

Consumer Rights Form

Share on print
Print

First Name ____________________________________________________________________________________________

Middle Name / Initial   _________________________________________________________________________________

Last Name ________________________________________________________________________________________________

Address ___________________________________________________________________________________________________

Address 2 _________________________________________________________________________________________________

City   _________________________________________   State ________________________   Zip _______________________

Phone Number   _________________________________________________________________________________________

Email Address   __________________________________________________________________________________________

Policy #   __________________________________________________________________________________________________

Claim # (if applicable)  _________________________________________________________________________________

Policyholder Name ______________________________________________________________________________________

Information Requested _________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Preferred Method of Response __________Phone   ________ Email

Authorization Signature___________________________________________________________________________________

Date ___________________________________________________________________________________________________________

Printed from: https://kwspecialty.com/california-consumer-privacy-act/

KW Specialty Insurance
P.O. Box 15310
Scottsdale, AZ 85267-5310

Phone: 1.855.CALL.KWS (225-5597)