Privacy Rights Request Form

This form applies only to state residents of California, Colorado, Connecticut, Virginia, and Utah. For all other privacy-related information or inquiries, please contact us at Privacy@tristargroup.net.

We are required to verify your identity before we process your request. Please complete the form in its entirety so we may accurately verify your identity:

First Name*

Last Name*

Email*

Phone*

State*

Select (check) the TRISTAR business division, subsidiary, or affiliate that applies to your request*

Select (check) the option or options that best describe your interaction with TRISTAR*

You are a personal lines client with direct interaction with TRISTAR

Your employer’s workers’ compensation or other insurance is administered by TRISTAR

Your employer’s health benefit program or leave of absence is administered by TRISTAR

You have a claim that is being or has been handled or administered by TRISTAR.

You are a resident of California and are a current or former Employee of TRISTAR.

You are a resident of California and have applied for a position with TRISTAR directly or through an online application or website

Other

Please include additional information below that will help us identify you or your information or data

Provide the date range for your request of information that you believe TRISTAR collected about you (example: Start Date mm/dd/yyyy through End Date mm/dd/yyyy):

Start Date	End Date

Describe or name the Service provided, relationship, or interaction with TRISTAR associated with this request (as applicable)

Provide the applicable policy number, claim number, or member I.D. number.

Select (check) only one request type:

Right to delete information that TRISTAR has collected about you

Right to know

Right to correct

Right to portability

Right to opt out of processing your data for automated decision-making that produces legal or significantly similar effects concerning you (only applicable to residents of Colorado, Connecticut, and Virginia)

Other

Additional Request Details*

I declare under penalty of perjury that I am the individual whose personal information is the subject of this request.*

I declare under penalty of perjury that I am the Authorized Agent of the individual whose personal information is the subject of the request. I understand I will be required to provide proof in writing of my status as the individual’s Authorized Agent and additional information to confirm the individual’s identity.*

By submitting this form, I hereby certify that the information provided is complete, accurate, and current. I understand that it may be necessary for TRISTAR to verify my identity and/or the identity of the authorized agent for this request, and additional information may be requested for this purpose.

*Indicate required information

TRISTAR Service Company	TRISTAR Insurance Services
TRISTAR Risk Management	TRISTAR Integrated Absence Management
TRISTAR Claims Management Services	Aspen Risk Management
TRISTAR Managed Care	Hazelrigg
TRISTAR Benefit Administrators	I do not know
TRISTAR ICS	Other