Request to Access Verification Form

First Name *

Last Name *

Phone Number*

Address*

Email Address*

Please provide any other non-personal information/fact-based information [insert, e.g., provide the last date that you interacted with Coface] below.

Related Non-Personal Information:

Pursuant to applicable state law(s), you have the right to request that Coface North America Insurance Company disclose the information below that we collected about you from the preceding twelve (12) months from the date of receipt of the request. By your check mark(s) below, please indicate which information you are requesting.

A. Types of personal information that we have collected about you;

B. Categories of personal information that we have collected about you;

C. Categories of sources from which the personal information is collected;

D. Categories of personal information that we have sold, shared for cross-context behavioral advertising, or disclosed for a business purpose about you;

E. Categories of third parties to whom we have sold, shared for cross-context behavioral advertising, or disclosed the personal information for a business purpose;

F. The business or commercial purpose for collecting, selling, or sharing for cross-context behavioral advertising personal information.

Please choose the corresponding letter for your selection.*

A - Types of Info

B - Categories of Info

C - Categories of Sources

D - Categories of Personal Information

E - Categories of Third Parties

F - Business or Commercial Purpose for Collection

In addition, you have the right to know the categories of sensitive personal information we collect, if any, and the purpose(s) for which the categories of sensitive personal information are collected or used, and whether that information is sold or shared for cross-context behavioral advertising.

1. The categories of sensitive personal information we collect;

2. The business or commercial purposes for which sensitive personal information is collected;

3. Whether the sensitive personal information is sold or shared for cross-context behavioral advertising, as applicable.

Please choose the corresponding number for your selection.

Checkboxes*

1 - Categories of Sensitive Personal Information

2 - Business or Commercial Purposes of Collection

3 - Whether sensitive information is sold or shared

Please indicate any other details related to this request:

If your request is invalid for any reason, or if we require additional information to process this request, we will contact you directly using the contact information you provide to us on this form. This request is signed under the pains and penalties of perjury.

By entering your full name below, you consent to the use of your electronic signature.*

Please enter the date signed below.*

Enter your relationship to the Consumer (if other than named individual e.g. parent or guardian)

RETURN TO DATA REQUEST FORMS SELECTION PAGE.

Upon receipt of your completed form, we will determine whether we hold personal information about you and respond to your request within 45 calendar days. If we are unable to process your request within that time period, we may extend the response time for an additional forty-five (45) calendar days. In that case, we will notify you and explain the reason for the extension within the initial forty-five (45) day period.

Coface does not sell your information or share your information for purposes of cross-context behavioral advertising. While California residents have the right to opt-out of the sale and/or sharing of their personal information under the California Consumer Privacy Act, we do not sell or share personal information, and therefore, we cannot accommodate these requests. If our practices change, we will update our Privacy Statement and take any other necessary action to comply with applicable law. To review our Privacy Statement, click here.

Coface Services North America, Inc., is part of the Coface Group (“Coface”), which is authorized in France by the Autorité de Contrôle Prudentiel et de Résolution and is subject to regulation by the Financial Conduct Authority and limited regulation by the Prudential Regulation Authority. For our full terms and conditions, click here.