Consumer Information Request Form

ICW Group is committed to ensuring consumer privacy rights and personal information are protected. ICW Group adheres to applicable privacy regulations and provides consumers with convenient options to request their consumer information online, below, and telephonically by calling (866) 442-9477. For a complete statement of ICW Group’s privacy policy for California consumers per the California Consumer Privacy Act (“CCPA”), click here:

California Privacy Policy; Notice at Collection: https://www.icwgroup.com/CAprivacy/

The form below may be submitted by consumers in any state. ICW Group will respond in accordance with its applicable legal obligations under the laws of the state in which the consumer resides.

Be sure to clarify specifically what you want and explain your request in sufficient detail to that we can understand, evaluate and respond to your request.
You will need to generally describe the information involved, the nature of your request, the type of relationship the consumer has with ICW Group (injured worker, claimant, job applicant, employee, etc.), provide the consumer’s name, street address of the consumer’s primary residence, and contact information.
Only you or someone legally authorized to act on your behalf may submit a request. You should be prepared to identify yourself as the individual about whom ICW Group has collected information by providing proper identification or through other reliable means. We may ask you to confirm one or more pieces of information from our files to verify the consumer’s identity.
If you are submitting a request on behalf of a consumer other than yourself, you will need to explain your relationship to the consumer, provide your name and contact information, and be prepared to submit a power-of-attorney form or other authorization signed by the consumer or issued by a court of law designating you as the consumer’s lawful representative for purposes of making requests of this nature. This information will be required in addition to information sufficient to verify the identity of the applicable consumer.

Who is the request for?*
- Myself
- Someone else
Consumer's name*
First name Middle name Last name
Your (Representative's) Name:*
First name Middle name Last name
Personal Phone Number*
Personal Email Address*
Confirm Personal Email Address*
Your phone number*
Your email address*
Confirm your email address*
YOUR ADDRESS*
Street address 1 Street address 2 City State Zip
In what capacity do you represent the Consumer?
What documents do you have establishing your right to act on the Consumer’s behalf?
Consumer's name*
First name Middle name Last name
Consumer's personal phone number*
Consumer's personal email address*
Confirm consumer's personal email address*
State of Residence
STREET ADDRESS- CONSUMER’S PRIMARY HOME:*
Street address 1 Street address 2 City State Zip
What is the consumer's relationship with ICW Group?*
Type of request?*
Please clarify details of your request, specify particular records or information involved, applicable dates, and any additional details that may assist us in understanding what you want to achieve and enable us to respond to your request.
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