*Rural Community Insurance Company (RCIS) is a wholly owned subsidiary of Zurich American Insurance Company (Zurich).
Residents of Arizona; California; Connecticut; Georgia; Illinois; Maine; Massachusetts; Minnesota; Montana; New Jersey; Nevada; North Carolina; Ohio; Oregon; and Virginia are provided privacy rights based on current legislation. For further information surrounding these rights, please review our online Privacy Policy found at
https://www.zurichna.com/en/services/privacy-policy or contact us at
privacy.office@zurichna.com.
Instructions: Please complete the required fields below. In the event of multiple policies, claims, or appointments, please provide all numbers to which your request pertains. Information collected on this form will be used and retained only to process your request.
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1) Tell us your name:
First Name *
Middle Name
Last Name *
State of Residence *
2) How may we contact you:
Email address
Email Address *
ⓘ
We ask for your email address to validate your identity and in the event we may need to contact you.
Phone number
3) Are you submitting this request for yourself or on behalf of another individual?
Self
Other individual
4) What is your relationship to Zurich? (select all that apply)
Insured
Please list applicable policy numbers here.
Claimant
Please list applicable claim numbers here.
Employee
Please list applicable Employee number here.
Broker
Please list applicable Producer Appointment ID number here.
Other
Please provide details that will help us verify your request.
4) What is your relationship to the individual for whom you are submitting this request:
Power of Attorney
Broker
Other
Please explain your relationship to the individual for whom you’re submitting this request.
5) Please provide the following information about that individual:
First Name *
Middle Name
Last Name *
State of Residence *
6) How may we contact that individual:
Email address
Email Address *
ⓘ
We ask for the individual’s phone number in the event we may need to contact him/her.
Phone number
7) What is that individual’s relationship to Zurich? (select all that apply)
Insured
Please list applicable policy numbers here.
Claimant
Please list applicable claim numbers here.
Employee
Please list applicable Employee number here.
Broker
Please list applicable Producer Appointment ID number here.
Other
Please provide details that will help us verify your request.
Please specify the nature of the request:
Send information to (please select one):
Email Address:
Mailing address:
Information to be corrected:
Nature of request:
How did you or the individual for whom you are submitting this form become aware of the privacy rights (select all that apply)?
Nature of request: