Granite Re, Inc.

First Name

Middle Name

Last Name

Address

City

State

Zipcode ZIP Format: ##### or #####-####

Driver's License Number

Issue State

Phone Number Phone Number Format: (###) ###-####

Phone Type

Alternate Phone Number Phone Number Format: (###) ###-####

Alternate Phone Type

E-Mail

Date Of Birth Date Format: mm/dd/yyyy

SSN (last 4 digits)

Is the subject a CA resident?

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

Commercial Property & Casualty account

Business/Insured Name

Granite Surety Insurance - bond principal

Related Business

Claim (connected to a Commercial Property & Casualty policy)

Claim Number

Federated Trade Association member

Federated Challenge Fundraising attendee/donor

Employee

Former Employee

Retiree

Applicant not hired

Contractor

Business Name of Contractor

Life, Disability Income, or Annuity policy

Claim (connected to a Life, Disability Income, or Annuity policy)

Other

(Please specify)

What is your preferred method of delivery?

I am requesting Granite to:

Disclose elements required by law related to:

Categories of Personal Information Granite 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 Granite disclosed for a business purpose about the consumer.
Specific pieces of Personal Information that Granite has collected about the consumer.

Delete the subject’s Personal Information which Granite has collected about the consumer, as required by law.**
[Granite will respond to the requestor. Granite may choose to de-identify or aggregate the personal information. Granite will maintain a record of the request for record-keeping purposes, as required by CCPA. If we cannot verify the identity of the requestor Granite may deny the request.] **Exceptions may apply.

Correct inaccurate information that Granite maintains about the consumer.**
[Granite will accept, review and consider all documentation provided by consumer/requestor or requested by Granite. Consumer should make a good-faith effort to provide Granite with all necessary information available at the time of the request. Granite may request the consumer/requestor to provide documentation to rebut its own documentation that the personal information is accurate. Please note that Granite may deny a request to correct if it determines that the contested personal information is more likely than not accurate based on the totality of the circumstances or has a good-faith, reasonable, and documented belief that a request to correct is fraudulent or abusive.] **Exceptions may apply. If an exception applies we will explain that basis in our response.

Type of Correction

I am the California consumer ("subject" above) who is making the request about my own personal information.

I am a natural person acting as the “Authorized Agent” requesting information on behalf of the California consumer who is the subject of this request. I agree to comply with the requirements for the use of Authorized Agents as specified below.

I am a business entity acting as the “Authorized Agent” requesting information on behalf of the California resident who is the subject of this request. I have been authorized by the subject of this request to act on his/her behalf. I agree to comply with the requirements below.

Entity Number assigned by the California Secretary of State

IMPORTANT INFORMATION FOR AUTHORIZED AGENTS AND CONSUMERS USING AUTHORIZED AGENTS: If you, the Authorized Agent, have a valid power of attorney pursuant to California Probate Code sections 4121 to 4130 we will require you to provide a copy of that to us before we will provide any information or take any action requested pursuant to the request. If you do not have a valid power of attorney, Granite will require the Authorized Agent to provide (1) proof that the subject of this request/consumer gave the agent signed permission to submit the request, and (2) The consumer/subject must also directly confirm with Granite that they provided you, the Authorized Agent, permission to submit the request. Consumers and Authorized Agents should contact Granite at the toll-free-number 1-844-929-0147 or by e-mail at consumerdatarequest@fedins.com to provide information/documentation as required above.

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. 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

Typed Name

Business Name

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