CCPA Information Request
All fields must be completed for your request to be processed. For authorized agents: unless otherwise specified, you must fill out the form using the authorizer's information.
Completed forms must be mailed to: FocalPoint Marketing
Attn: CCPA Coordinator
P.O. Box 43
Clinton, LA 70722
Full Name
_________________________________ ________________________________
First Last
Email Address -- the one that received the Insurance Industry email
_______________________________________________________
Business Phone Number
_____ - _____ - __________
### ### ####
Business Address
________________________________________________________________
Street Address
________________________________________________________________
Address Line 2
_________________________ _____________________ ________________
City State Postal / Zip Code
Request Type (Check all that apply)
__ Access -- send me a report with the personal information that is collected, used, disclosed and given to others
__ Delete -- delete my personal information from your records
__ Opt-out -- do not share my information with others
I am making this request on behalf of:
__ Myself
__ Someone else (fields below must be completed to process request)
Authorized Agent's Name
_________________________________ ________________________________
First Last
Authorized Agent's Email Address
_______________________________________________________
Authorized Agent's Business Phone Number
_____ - _____ - __________
### ### ####
I declare under penalty of perjury that I am the individual consumer whose personal information is the subject of this request OR I am the authorized agent of the individual whose personal information is the subject of this request.
Requestor's signature Date
________________________________________________ ___________________