California Consumer Privacy Act Request Form

The information provided in this form will only be used to verify your identity and to determine whether we have collected and retained any of your personal information in our records. We will not use this information for any other purpose. If we cannot verify your identity with a sufficiently high degree of certainty, we will be unable to provide any information in response to your request.

Please correct the information below
We're sorry, but we are unable to process your request. Please try again or contact (877) 671-7879 for further assistance.
Name

Please enter your first name

Please enter your last name

Please enter a valid date

CA Mailing Address
Additional Address

Please enter your address

Please enter a house number and a street name, separated by a space

Please enter your city

In order to verify your residency, please enter a valid CA Residential Address

+Add another address

Please enter a valid phone number

+Add another phone number

Please enter your email address

Please enter a valid email address

How should we respond to you?*

Please provide a response method

If you are making this request on behalf of another consumer or a minor child - please explain:

The following information is not required, but may enable us to locate your information in our records:

Are you currently, or have you ever been, a Mercury Insurance customer?
What type of insurance? (check all that apply)

Please provide at least one policy type

Please provide your Mercury Insurance policy number(s) if known:
+Add another policy number
Have you had a claim with Mercury?
Please enter your claim information if known:

Please enter a valid date in MM/YYYY format

+Add another claim number