CCPA Request Form

*Required field

State of Residence of the Individual Whose Information is Subject of the Request.*

Please mark whose information you are requesting*

Information collected about yourself
Information collected about another person
Information about a household

Please specify your request:*

Request Information Collected about You
Request Deletion of Your Information
Request a Copy of Your Information

Please specify if you are requesting categories of information collected or specific information collected:*

Categories of personal information collected in the prededing twelve (12) months
Specific pieces of personal information collected in the preceding twelve (12) months

PLEASE FILL OUT THE FOLLOWING INFORMATION:

Name (Full First and Last Name)*
Title (if applicable)
Company (if applicable)
Street Address*
City*
State*
Zip Code*
Phone (xxx-xxx-xxxx)*
Email*


I have read Ambac's Privacy Policy*