Submit a U.S. Multi-State Privacy Request

Fields marked with an * are required

Use this process to exercise your rights.

The types of requests you can submit through this process are as follows:

Request to know the categories of information we collect and share about you.
Request to know what specific pieces of information we collect about you.
Request that we delete your information.
Request that we correct your information.

Please be advised that this process is intended only for submissions about one individual and is not intended for submitting request about multiple people.

You are making a request for a resident of one of the states listed below:
California, Colorado, Connecticut, Delaware, Indiana, Iowa, Kentucky, Montana, Nebraska, Nevada, New Hampshire, Rhode Island, Texas, Utah, Virginia, Washington

Who is this request for?

*All information is required, unless marked optional.

Full Name of Person

Daytime Phone

Address

Address Line 2

Zip

Type of Request *

Request to know the categories of information we collect and share about you.

Request to know what specific pieces of information we collect about you.

Request that we delete your information.

Request that we correct your information.

Please enter YOUR information
As the representative for the person above, we will be contacting you.

Describe your relationship to the individual and authority to act on their behalf

Relationship

Your Full Name

Daytime Phone

I certify under penalty of perjury that I am the individual named in this form, or I am a duly authorized representative acting on his/her behalf, and the information provided herein is accurate and complete to the best of my knowledge. *

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Stop Loss coverage is underwritten by HM Life Insurance Company, Pittsburgh, PA, in all states except New York, under policy form series HMP-SL (08/19) or HMP-SL (06/20) or similar. In New York, Stop Loss coverage is underwritten by HM Life Insurance Company of New York, New York, NY, under policy form series HMP-SL (06/20) or similar. In all states except New York, Provider Excess Insurance is underwritten by HM Life Insurance Company, Pittsburgh, PA, or Highmark Casualty Insurance Company, Pittsburgh, PA, under policy form series HM PEL 1105, HC PEL 1105, HMP PEL (09/20) or similar. In New York, Provider Excess Insurance is underwritten under policy form series HMNY PEL1105 or similar. In all states except New York, Assumed Accident and Health Reinsurance is underwritten or reinsured by HM Life Insurance Company, Pittsburgh, PA, or Highmark Casualty Insurance Company, Pittsburgh, PA, under form HM1005-ELR or similar. In New York, Assumed Accident and Health Reinsurance is reinsured by HM Life Insurance Company of New York, New York, NY. The coverage or service requested may not be available in all states and is subject to individual state approval. Reinsurance agreements only reflect a form number when required by applicable state law.