Opt Out Election Form
Please read this Opt Out Election Form and indicate whether you wish to exercise your right to Opt Out of the information sharing described in TRANSGUARD’s Privacy Notice. If you choose to exercise your right to Opt Out, you must complete this form and click the “SUBMIT” button at the bottom of this page.
If you are a Premier Program Customer, please check this box:
If you are an Independent Contractor Customer, please check this box:
If you are a new customer, we can begin sharing your information 30 days from the date we sent the Privacy Notice to you. When you are no longer our customer, we continue to share your information as described in the Privacy Notice, and/or as permitted or required by applicable law. However, you can contact us at any time to limit our sharing.
I wish to exercise my right under the Gramm-Leach-Bliley Act to Opt Out of this Company's sharing of nonpublic personal information about me with nonaffiliated third parties for purposes other than those permitted or required by applicable law.
I wish to exercise my right under the Fair Credit Reporting Act to Opt Out of this Company's sharing non-transactional information about me with affiliates for purposes other than those permitted or required by applicable law.

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099038 06/11	TRANSGUARD INSURANCE COMPANY OF AMERICA, INC.