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 about the consumer.

Delete the subject’s Personal Information, as required by law.**

** 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

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