Disclose PI | The General Car Insurance

First Name:

Last Name:

Date of Birth:

Email:

Phone Number

Residence State:

State Not Found

Driver's License Number:

Claimant Name:
(If Applicable)

Accident Date:
(If Applicable)

Information Type Requested:

Policy
Claim
Quote
Employment
Other

Information Requested:
(Additional Detail)

Type of Request:

Purpose(s) of Collecting Personal Information

Specific Details of Personal Information Collected

Personal Information Shared

Purpose(s) for Sharing Personal Information

Personal Information Sold

Categories of what Information is Collected, Sold or Shared

Delete Personal Information which can be Deleted, Not Subject to Exception

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Privacy Request