Consumer Privacy Form

Welcome to the Riverside Insurance Marketing, Inc. California Consumer Privacy Form

After completing this form, the team at Riverside Insurance Marketing, Inc. will review your submission and search our data stores for any personal information that may be held about you. We will verify identity by matching the data that you have provided to data that we may hold. Please expect responses to your request within 45 days of your form submission.

I am submitting this information on behalf of:

For Myself On Behalf of someone else

Select the Right You Want to Exercise:

Request to Know Request to Delete

First Name

Date of Birth

Phone Number

Request Details

Acknowledgement
By providing my name as signature below, I declare under penalty of perjury that I am a California resident, the information that I have supplied in this application is correct and I am the person to whom it relates. I understand that attempting to obtain the personal data to which you are not entitled is a legal offense.By providing my name as signature above, I declare under penalty of perjury that I am a California resident, the information that I have supplied in this application is correct and I am the person to whom it relates. I understand that attempting to obtain the personal data to which you are not entitled is a legal offense.

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Riverside Insurance Marketing, Inc.
2750 Taylor Ave., Suite A-63
Orlando, FL 32806
Main: 407.362.7744