California Consumer Privacy Act (CCPA) Request form for California Residents Who is the request for?* Myself Someone else Consumer's name* First name Middle name Last name Your (Representative's) Name:* First name Middle name Last name Personal Phone Number* Personal Email Address* Confirm Personal Email Address* Your phone number* Your email address* Confirm your email address* YOUR ADDRESS* Street address 1 Street address 2 City State Zip In what capacity do you represent the Consumer? What documents do you have establishing your right to act on the Consumer’s behalf? Consumer's name* First name Middle name Last name Consumer's personal phone number*Consumer's personal email address* Confirm consumer's personal email address* State of Residence STREET ADDRESS- CONSUMER’S PRIMARY HOME:* Street address 1 Street address 2 City State Zip What is the consumer's relationship with ICW Group?*Select a relationshipInjured WorkerI have/had a claim with ICW GroupOtherType of request?*Request for consumer's informationCorrection of inaccurate consumer informationDelete consumer informationOtherPlease clarify details of your request, specify particular records or information involved, applicable dates, and any additional details that may assist us in understanding what you want to achieve and enable us to respond to your request.Please prove you're not a robot by entering the text in this image into the field below Notice of Collection of Personal Information