CCPA Request Form

The California Consumer Privacy Act of 2018 as amended, including by the California Privacy Rights Act of 2020, and any applicable regulations (“CCPA”) is meant to enhance privacy rights and consumer protection for residents of California. This law applies to all California residents and allows them the right to access their personal information that we have collected and stored, the right to correct their personal information, and the right to request that we delete their stored personal information subject to exemptions within the law. Additionally, you have the right to opt out of the sale and sharing of your personal information with third parties for the purpose of cross-context behavioral advertising.

Are you a California resident or do you reside in California for more than six months out of the year?

Yes No Please select Please let us know if you are a CA resident.

At this time only California residents are eligible to submit requests.

Please go back to learn more about CCPA/CPRA.

What do you want to do?

Access my personal information Correct my personal information Delete my personal information Do not sell or share my personal information Please select Please select what you want to do

Request for Access to Personal Information

Request for Correction of Personal Information

Request for Deletion of Personal Information

Do not sell or share my personal information

I request that Amica disclose the following as applicable for the past 12 months (Choose all that apply.):

The categories of personal information collected about me The specific pieces of personal information collected about me The categories of sources from which my personal information was collected The business or commercial purposes for collecting my personal information The categories of third parties to whom Amica discloses my personal information The categories of personal information that the business disclosed about me for a business purpose Please select all options applicable

I request that Amica correct my personal information it maintains as follows:

Describe the personal information and how you want it to be corrected. (2000 characters remaining)

Please complete this form.

I understand that, while I have the right to request correction of my personal information identified above, Amica may be unable to correct the information as requested if the correction would be impossible, would involve disproportionate efforts, or because the information is otherwise accurate. I understand that Amica may also be unable to correct the information because of reasonable concerns regarding the accuracy of the information to be corrected, or because of reasonable concerns regarding fraud.

How do you want us to deliver the requested information? (Choose one.)

Mail Email Please enter your preference

Indicate how you prefer we communicate with you. (Choose one.)

Mail Email Please enter your preference

Please Enter your email ID

I request that Amica delete my personal information it maintains or processes. I understand that, while I have the right to request deletion of my personal information, Amica may be able to retain some or all of the personal information for a variety of reasons, such as to comply with a legal obligation.

I request that Amica no longer sell or share my personal information with third parties for the purpose of cross-context behavioral advertising.

First Name

Please enter your first name

Last Name

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Street Address

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City

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State

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ZIP Code

Please enter your zip code

Email Address

Please enter a valid email address.

Please Enter your email ID

Optional

Telephone number

Please enter a valid phone number

Please Enter your email ID

Birth Month & Year

MM/YYYY

Please enter your birth month and year

Optional

Birth Month & Year

MM/YYYY

Please enter your birth month and year

Choose all that apply:

I'm an Amica customer. I’m an Amica job applicant, employee, former employee, retiree, pensioner, director or contractor. I’m not an Amica customer. Please select your status

Policy Type

Auto Home Life Condo Renters Umbrella Marine Motorcycle Retirement Other Please select all that apply

Auto policy number

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Auto policy effective start date

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Auto policy effective end date

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Home policy number

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Optional

Home policy effective start date

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Home policy effective end date

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Life policy number

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Life policy effective start date

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Condo policy number

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Condo policy effective start date

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Condo policy effective end date

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Renters policy number

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Renters policy effective start date

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Renters policy effective end date

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Umbrella policy number

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Umbrella policy effective start date

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Umbrella policy effective end date

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Marine policy number

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Marine policy effective start date

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Marine policy effective end date

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Motorcycle policy number

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Motorcycle policy effective start date

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Motorcycle policy effective end date

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Retirement policy number

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Retirement policy effective start date

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Retirement policy effective end date

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What is the other product you own and its policy number? (2000 characters remaining)

Please fill up this field

Describe your relationship with Amica: (2000 characters remaining)

Please enter your relationship with Amica.

Have you ever had a policy with Amica? If so, provide the policy number:

Optional

Policy number

Have you quoted with Amica, or are you a current insurance applicant? If so, provide the sales or reference number/quote ID:

Optional

Reference number/quote ID

Are you, or have you been, a claimant or witness? If so, provide the claim number:

Optional

Claim number

Are you, or have you been, an Amica Life beneficiary? If so, provide the policy number:

Optional

Policy number

Have you received marketing communications from Amica by mail or email? If so, provide the email address:

Optional

Email address

Optional

Other (describe):

I understand that I may make a verifiable consumer request for access or data portability twice within a 12-month period. Please check this box before proceeding.

By clicking “Submit,” I am declaring under penalty of perjury that I am the California resident whose personal information is the subject of this request.

Send us a request

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