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Privacy Rights Request Form

Applicable only to residents of the United States

If you are a resident of the United States, please complete the form below. For all other privacy related inquiries, please contact us at GlobalPrivacyOffice@ajg.com.

Complete this form to help us verify your identity and take any appropriate action on your data request. Our support team will respond to your request promptly. Thank you.

We are required to verify your identity prior to complying with your request. In order to verify your identity, please provide the following information:

First Name *

Last Name *

Email *

Phone *

State *

Select the Arthur J. Gallagher & Co. (“Gallagher”) business entity that relates to your request: *

Select which options best describe your relationship with Gallagher (select all that apply). *

You are a personal lines client and have a direct relationship with Gallagher

Your employer places injury or other insurance through Gallagher

Your employer places health benefit insurance through Gallagher

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

You are a resident of California and are a current or former Employee of Gallagher

You are a resident of California and have applied for a position at Gallagher through a direct relationship or online application

Other

Any other information that may help us identify you or your data?

Type of insurance coverage associated with this request (if applicable)

Policy Number (if applicable)

During what time period do you believe Gallagher collected your information (i.e., dd/mm/yyyy - dd/mm/yyyy):

Request Type (select one) *

Right to delete information that Gallagher has collected about you

Right to know

Right to correct

Right to portability

Right to opt out of processing of your data for automated decision making that produces legal or significantly similar effects concerning you

Right to opt out of the Processing of Sensitive information

Other

Right to know (select all that apply)

Specific pieces of information that Gallagher has collected about you

Categories of information that Gallagher has collected about you

Categories of information that Gallagher has disclosed about you and the categories of third parties to whom the information was disclosed

Categories of sources from which Gallagher has collected information about you

The business or commercial purpose for which Gallagher has collected your information

If right to correct is selected, please identify data that you wish to have corrected:

If other is selected, please provide details:

Additional Request Details

Please read and select the applicable option below: *

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 entered into this form is complete, accurate, and up‐to date. I understand that it may be necessary for Gallagher 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 fields