Verifiable California Consumer Data Request

Subject's Legal Name

First Name (required)

Middle Name

Last Name (required)

E-mail Address (required)

Phone Number (required)

Phone Type (required) Select One Home Cell Business

Address (required)

City (required)

State (required) Select 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

ZIP

Driver's License Number

Issue State Select 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

Date of Birth (required)

Social Security Number (Last 4 Digits) (required)

Is the subject a resident of California? (required) Select One Yes No

Subject is affiliated with Federated by a: (Select all that apply)

Preferred Method of Delivery (required) Select One E-mail US Post

I am requesting Federated to:

• Categories of Personal Information Federated has collected about the consumer.
• Categories of sources from which Personal Information is collected.
• The business or commercial purpose for collecting Personal Information.
• Categories of third parties to whom Personal Information was disclosed for a business purpose.
• Categories of Personal Information that Federated disclosed for a business purpose about the consumer.
• Specific pieces of Personal Information that Federated has about the consumer.

*exceptions may apply

By signing this document I hereby declare under penalty of perjury, pursuant to the laws of the United States of America and any applicable state laws, that I am the person making the request and that I have sufficient legal authority to make the request. I understand that falsifying any information could subject me to civil and criminal penalties.

Further, by typing your name or electronically signing this form you agree that your e-signature is legally binding and valid and serves as your original signature.

Signature (required)

By clicking on Submit below, you acknowledge that you have read and agree to Federated Insurance Company's Terms and Conditions and Federated's Privacy Policy.