Granite Re, Inc.

This request is currently available to California residents. Please complete the form below in its entirety and best of your ability. Failure to do so may slow our response time or prevent disclosure.

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

E-Mail

Date Of Birth Date Format: mm/dd/yyyy

SSN (last 4 digits)

Is the subject a CA resident?

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

Commercial Property & Casualty account

Life, Disability Income, or Annuity policy

Granite Surety Insurance - bond principal

Related Business

Claim (connected to a Commercial Property & Casualty policy)

Claim Number

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

Federated Trade Association member

Federated Challenge Fundraising attendee/donor

Other

(Please specify)

What is your preferred method of delivery?

I am requesting Federated to:

Disclose elements required by law related 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 collected about the consumer.

Delete the subject’s Personal Information which Federated has collected about the consumer,
as required by law.**

** Exceptions may apply.

I am the California resident (“subject” above) who is requesting information about myself

I am a natural person acting as the “Authorized Agent” requesting information on behalf of
the California resident 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, Federated 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 Federated that they provided you, the Authorized Agent, permission to submit the request. Consumers and Authorized Agents should contact Federated 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.

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

Typed Name

Business Name

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