REVIEWING YOUR PERSONAL INFORMATION
DATA SUBJECT ACCESS REQUEST (DSAR) SUBMISSION FORM


State and federal laws provide individuals (or data subjects) with certain rights related to their personal information (PI). These rights are called Data Subject Access Requests or DSARs, and they include:
  • the right to know what PI business have collected about them
  • the right to access that PI
  • the right to correct the PI
  • the right to request deletion of certain PI


QBE North America (QBENA) and its affiliates do not sell customer PI or share it with unaffiliated third parties. Limited sharing of PI occurs to administer and service accounts. For this reason, QBENA does not provide an option to “opt out” of sharing PI.

As an insurance company, QBENA is governed by the privacy requirements of the federal Gramm-Leach Bliley Act (GLBA) and state insurance laws. Some state insurance laws permit individuals to access recorded PI held by regulated entities, which require insurers to respond within 30 days. Where possible, QBENA will honor all requests related to PI, provided they do not conflict with data retention policies or other laws.

To submit a data subject access request under any state or federal law on behalf of yourself or another individual, you may:
Requester Information
Requested for? * Relationship, if Other
First Name *
Last Name *
Suffix
   
Primary Phone *
Email
Consumer Information
First Name *
Last Name *
Suffix    
Primary Phone *
Email
Date of Birth *
  		 
Permanent / Primary Address
Country *
Address Line 1 *  
Address Line 2  
City *  
State *  
Zip Code *
 
Mailing Address            
Country *  
Address Line 1 *  
Address Line 2  
City *  
State *  
Zip Code *
 
Other Details
Policy Holder? *         Quote Holder? *          Other?
If yes, policy number(s) / quote number(s):





Request Type *
Right to Access - Categories of Data
The right for you to know what categories of personal information are collected, used, or shared about you

Right to Access - Specific Data Elements
The right for you to know what specific pieces of personal information are collected, used, or shared about you, and the right to receive such specific pieces of personal information in an accessible electronic or hardcopy format.

Right to Access - Both
The right for you to know and receive both the categories and specific pieces of personal information that are collected, used, or shared

Right to Erasure
The right for you to have your personal information held by businesses deleted, unless retention of the information is required or permitted by applicable law.
 
Previously requested? *    If yes, Request number  
Comments:
Contact Preference
Please select how you would like to be contacted. Please select at least one method  *