California Privacy Request | United Heartland

California residents can use this form to submit requests under the California Consumer Privacy Act (CCPA) regarding personal information collected by Accident Fund Holdings, Inc. dba AF Group and its affiliates (“AF Group”). This form can be used for a Do Not Sell request, Right to Know request, or Right to Delete request.

AF Group reserves the right to refuse requests, in whole or in part, to the extent permitted by law, including due to an inability of AF Group to verify your identity or verify your authority to act on behalf of the consumer who is the subject of the request. For certain requests, we may ask for additional information or documents for verification purposes.

AF Group will use the information you provide through this form to respond to your request, including verifying identify, identifying personal information responsive to your request, and keeping records of your request.

California residents have the right to designate an authorized person or corporate entity¹  to exercise rights granted to them under the California Consumer Privacy Act (“CCPA”). To make this designation, California residents may complete and submit an Authorized Agent Designation Form to AF Group. Download Here

If AF Group is unable to verify the identity of the person submitting this form, we may request additional information from the person making the submission. AF Group may deny a request from an authorized agent if the agent cannot provide to AF Group the consumer’s signed permission demonstrating that they have been authorized by the consumer to act on the consumer’s behalf. Authorized agents that have been provided a power of attorney from a consumer may submit requests directly on behalf of that consumer so long as proof of such power is submitted along with the consumer request form.

¹ If designating a corporate entity to act on your behalf, AF Group requires that such entity be registered with the California Secretary of State. AF Group will not provide information to unregistered agents.

I am a(n)
Which would you like to request?

Check if State of Residence is California or was in the immediate last 12 months

The CCPA and this Request Form applies to California Residents (including those in the immediate last 12 months) only.

Consumer’s Information:

Name
Phone
Email Address
Street Address
City
State
Policy or Claim Number (if applicable)
Comment (optional)

California residents have the right to designate an authorized person or corporate entity to exercise rights granted to them under the California Consumer Privacy Act ("CCPA"). To make this designation, California residents may complete and submit an Authorized Agent Designation Form to AF Group.

If AF Group is unable to verify the identity of the person submitting this form, we may request additional information from the person making the submission. Authorized agents that have been provided a power of attorney from a consumer may submit requests directly on behalf of that consumer so long as proof of such power is submitted along with the consumer request form.

Authorized Agent’s Information

Name
Phone
Email Address
Street Address
City
State

By submitting this form, I hereby certify that the information entered into this form is complete and accurate, and that I am the consumer who is the subject of the request or have been authorized by that consumer to act on his/her behalf, as indicated above. I understand that AF Group may need to request additional information in order to verify the identity of the consumer and/or authorized agent for this request.

Please email [email protected] the completed “Authorized Agent Designation Form” signed by the consumer that details the request.