California Consumer Privacy Act (CCPA) Request form for California Residents

The CCPA provides California consumer specific rights regarding their personal information that ICW Group may hold, unless applicable exceptions apply. For more information on the CCPA's consumer rights, see ICW Group’s Legal Notice & Privacy Policy.

You may use this form to submit your request as permitted by the CCPA. The CCPA requires us to verify both your identity and/or your authorization to act on behalf of the consumer. After submitting your request, ICW Group’s Data Privacy Team will contact you for additional information.

This form is intended for California residents only. Information you provide in connection with your request will not be used for marketing purposes.
Who is the request for?*
- Myself
- Someone else
Are you a current California resident?*
- Yes
- No
Is this person (the consumer) a current California resident?*
- Yes
- No
Sorry, this service is only available for current California residents.

For more information, see the Legal Notice & Privacy Policy.
Consumer's name*
First name Middle name Last name
Consumer's phone*
Consumer's email address*
Confirm consumer's email address*
Consumer's address*
Street address 1 Street address 2 City State Zip
What is the consumer's relationship with ICW Group?*
What company is/was the policy under?*
(Please only provide the name)
What is/was the name of the claimant's employer?*
(Please only provide company name)
Other Association*
Please describe your request.*
(e.g. I would like to know what personal information ICW Group has collected about me)
Relationship to the consumer*
(Proof of authorization to act of behalf of the consumer will be required.)
- Parent/guardian of the minor customer
- Power of Attorney for the consumer
Your name*
Your phone number*
Your email address*
Confirm your email address*
Consumer's name*
First name Middle name Last name
Consumer's phone*
Consumer's email address*
Confirm consumer's email address*
Consumer's address*
Street address 1 Street address 2 City State Zip
What is the consumer's relationship with ICW Group?*
What company is/was the policy under?*
(Please only provide the name)
What is/was the name of the claimant's employer?*
(Please only provide company name)
Other Association*
Please describe your request.*
(e.g. I would like to know what personal information ICW Group has collected about me)
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Notice of Collection of Personal Information