Home Office: 39 Public Square ● P.O. Box AH ● Wilkes-Barre, Pennsylvania 18703-0020
570-825-9900 ● 800-673-2465 ● www.guard.com ● Ed-10/2020
GUARD
Berkshire Hathaway
Companies
Insurance
California Consumer Privacy Act Request Form
California residents have the right under the California Consumer Privacy Act (CCPA) to request access
to the personal information collected about them and the right to opt out of the sale of personal
information. California residents may also have the right to request the deletion of some personal
information, subject to certain exceptions.
Please complete the questions below and return to us via email at privacy@guard.com or via U.S.
postal service using the address shown below. We reserve the right to refuse a request if we cannot
verify your identity or your authority to act on another individual’s behalf. If you have any questions,
please feel free to contact one of our Customer Service Representatives at 800-673-2465.
Full Name: ____________________________________________________________________
Street Address: ________________________________________________________________
City, State, Zip: ________________________________________________________________
Contact email: _________________________________________________________________
Insured/Business Name: __________________________________________________________
Please select which type of consumer you are and provide the appropriate information so we can
attempt to identify you and fulfill your request.
Policyholder: ________________________________________________________________
(Provide your policy number or customer ID.)
Claimant: __________________________________________________________________
(Provide your claim number.)
Other: _____________________________________________________________________
(Provide identifying information.)
If you are an Authorized Agent making this request on behalf of another individual, in order to process
your request, we will also need you to include with this form one of the following:
1. Written permission from the consumer that includes the consumer’s name, address and
identifying information (policy number, claim number, other) that states the Authorized
Agent may make requests on their behalf and confirm their identity with us.
2. Proof of Power of Attorney of the Authorized Agent pursuant to Probate Code sections
4000 and 4665.
What action(s) are you requesting? Please check all that apply.
Copy of personal information (If selected, please additionally select one or more below):
Categories of Personal Information Collected Specific Information Collected
Deletion of personal information
Do not sell personal information
Other (Explain): ______________________________________________________________
