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}}.