Web Policy Manager Implementation Form

What personal information do you collect? *

Name

Postal/Shipping Address

Billing Address

Phone Number

IP Address

Email Address

Alias

Online Identifier

Passport Number

State ID Card Number

Driver's License Number

Account Name

Social Security Number

Other

Policy Number (Insurance)

Subscriber's Identification Number (Insurance)

Unique Identifier Used by your Insurance Provider (Insurance)

Claims History (Insurance)

Appeals Records (Insurance)

Applications and Any Data Contained Therein (Insurance)

Other (Insurance)

School ID Number (Education)

Other (Education)

Card Expiration Date (Financial)

Credit or Debit Card Number (Financial)

Card CVV (Financial)

Bank Account Number (Financial)

Other (Financial)

Work ID Number (Employment)

Other (Employment)

Age (Medical/Protected)

Race (Medical/Protected)

Color (Medical/Protected)

National Origin (Medical/Protected)

Ancestry (Medical/Protected)

Religion (Medical/Protected)

Physical Disability (Medical/Protected)

Mental Disability (Medical/Protected)

Sex (Medical/Protected)

Pregnancy (Medical/Protected)

Gender (Medical/Protected)

Gender Identity (Medical/Protected)

Gender Expression (Medical/Protected)

Other (Medical/Protected)

Records of Personal Property (Commercial)

Products or Services Purchased, Obtained, or Considered (Commercial)

Purchasing or Consuming History or Tendency (Commercial)

Other (Commercial)

Imagery of the iris, retina, fingerprint, face, hand, palm, vein patterns or voice recordings (Biometric)

Keystroke Patterns or Rhythms (Biometric)

Gait Patterns or Rhythms (Biometric)

Sleep, Health, or Exercise Data (Biometric)

Other (Biometric)

Browsing History (Internet/Electronic)

Search History (Internet/Electronic)

Information Regarding Your Interactions with Our Website or Application (Internet/Electronic)

Information Regarding your Interactions with Advertisements (Internet/Electronic)

Other (Internet/Electronic)

Geolocation Information (Geolocation)

Audio, electronic, thermal, olfactory or other similar information (Audio)

Inferences drawn from any other information to create a profile about the consumer (Consumer Profiling)