CALIFORNIA OPT IN OPT OUT
Please use this form to submit a data subject rights request regarding your personal information under the California Consumer Privacy Act, as amended by the California Privacy Rights Act (“CCPA/CPRA”).
This form collects information in order to for us to respond to your personal information request. Required fields are indicated with an asterisk (*). The information you provide in your request will only be used for the purposes of identifying the personal information you are requesting and responding to your request.
Please check your email for a confirmation after submitting your request, click on the confirmation in the email you receive, and we will validate your request, confirm your identity, and start your request. If you do not click on the confirmation sent to your email address prior to its expiration, we will not be able to complete your request.
We will respond to your request within 45 days. If we need additional time, we will let you know that we need up to an additional 45 days.
Please do not provide or upload any sensitive personal information when completing this form such as social security number, driver’s license number, financial account number and health-related information.
For general information about our collection and use of personal information, please review our online privacy policy available on our website: Internet Privacy Policy
Are you submitting this request for yourself? If you are not, we will require documentation from the consumer in question that you are authorized to submit this request on behalf of the consumer.
Submitting Request for Myself
Submitting Request as an Authorized Representative of a Consumer
I am a / an (please select all that apply):
Job Applicant
Current Employee
Former Employee
Prospective Insured / Policyholder
Current Insured / Policyholder
Claimant
Agent or Broker
Client / Business Partner
Other
First Name
Last Name
Phone Number
Primary Address
Address Line 2
City
State
Zip
Country
Select your Personal Information Request Type:
Request to Know
Request to Access
Request to Delete
Request to Correct
Request Details
Please select your Method of Response Delivery:
Regular Mail
If this request relates to insurance, please provide the line(s) of insurance product(s) that the request relates to, if known:
If you have an agent or broker and would like to provide their information, please provide the agent or broker’s name, company, email address and phone number, if known:
If you are a claimant, have you had any contact with a third-party administrator (TPA) who is processing your insurance claim on behalf of NuSureCo Insurance Company, Inc.? If so, please provide the name of the TPA company.
By signing my name below, I certify under penalty of perjury that I am the individual or authorized representative of the individual making this request.
Toll-free phone number: 877-560-3108
Mail: NuSureCo Insurance Company, Inc.
Attention: Privacy Compliance
12140 Wickchester Ln Ste 600
Houston, Texas 77079
