This email was generated on {{currentDate}} {{currentTime}}.
Personal Information | |
---|---|
First Name: |
{{firstName}} |
Middle Name: |
{{middleName}} |
Last Name: |
{{lastName}} |
State of Residence: |
{{stateofResidence}} |
Email: |
{{emailaddress}} |
Phone Number: | {{phonenumber}} |
Other details (Self) | |
---|---|
Relationship to Zurich: |
|
Policy Numbers: |
{{insuredNum}} |
Claim Numbers: |
{{claimantNum}} |
Employee Number: |
{{employeeNum}} |
Producer Appointment ID: |
{{producerAppointmentId}} |
Other Details: |
{{otherDetails}} |
Relation to Individual | |
---|---|
Relation: |
{{relationToInd}}{{relationToIndOther}} |
Personal Information (individual) | |
First Name: |
{{indFirstName}} |
Middle Name: |
{{indMiddleName}} |
Last Name: |
{{indLastName}} |
State of Residence: |
{{indStateofResidence}} |
Email: |
{{indemailaddress}} |
Phone Number: |
{{indphonenumber}} |
Other details (individual) | |
---|---|
Relationship to Zurich: | |
Policy Numbers: |
{{indInsuredNum}} |
Claim Numbers: |
{{indClaimantNum}} |
Employee Number: |
{{indEmployeeNum}} |
Producer Appointment ID: |
{{intProducerAppointmentId}} |
Other Details: |
{{indOtherDetails}} |
Nature of Request | |
---|---|
Tell me what categories of personal information you have gathered about me and what that information is used for: |
{{myInfoEnquiryNOR}} |
Tell me with whom you have shared my personal information: |
{{enquiryNOR}} |
Obtain a copy of my personal information: |
{{emailNOR}}{{mailingAddressNOR}} |
Delete my personal information: |
{{deletionNOR}} |
Correct my personal information: |
{{InfoToBeCorrected}} |
Other: | {{natureofRequest}} |
How did you/he become aware of the privacy rights? | |
---|---|
THow did you or the individual for whom you are submitting this form become aware of the privacy rights?: |
{{privacyRightsAwarenessThrough}} |
Other: |
{{otherNOR}} |
This email was generated on {{currentDate}} {{currentTime}}.