California Consumer Privacy Act Request Form

The information provided in this form will only be used to verify your identity and to determine whether we have collected and retained any of your personal information in our records. We will not use this information for any other purpose. If we cannot verify your identity with a sufficiently high degree of certainty, we will be unable to provide any information in response to your request.

Name
CA Mailing Address
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+Add another phone number
How should we respond to you?*
If you are making this request on behalf of another consumer or a minor child - please explain:

The following information is not required, but may enable us to locate your information in our records:

Are you currently, or have you ever been, a Mercury Insurance customer?
Have you had a claim with Mercury?
Are you currently, or have you ever been, a Mercury Insurance employee, or applied for employment with Mercury Insurance?
Are you currently, or have you ever been, a licensed Mercury Insurance agent or broker?