Consumer Privacy Request | Goosehead Insurance

First Name

Last Name

Email

Phone

What State is your Residency?:

Privacy Disclosure:

Provide some details about your request

Please check the box to accept the privacy disclosure

We currently only accept privacy requests from California and Virginia

I acknowledge that I am a California resident and the person making the request noted above, under the California Consumer Privacy Act. I acknowledge that I am making this request in good faith on behalf of myself.

I CERTIFY AND DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT AND THAT I AM THE CONSUMER WHOSE PERSONAL INFORMATION IS THE SUBJECT OF THE REQUEST.

Confirm Privacy Disclosure

Please confirm privacy disclosure

Please check box if you are an authorized agent

If this request is being made on behalf of a consumer by an authorized agent, please send a copy of the signed permission to do so or provide the authorized agent power of attorney. This documentation can be mailed to Goosehead at 1500 Solana Boulevard, Ste. 4500, Westlake, TX 76262 or submitted via email to legal@goosehead.com.