Fill and Sign the Implementation Project Form

Opt-Out Request Form Send to: Household Insurance Group Holding Company Opt-Out P.O. Box 12405 Wilmington DE 19850 Please do not include any other correspondence with your request, and do not include this form with your payment. By checking the appropriate box(es) below, completing the requested information, and returning this form, you are requesting that we do not share your information (except as permitted or required by law), or that we do not allow our Affiliates to use your information for marketing purposes. This request applies only to the policy number(s) designated below. Sharing with Our Affiliates: I do not want my credit bureau information shared with other Affiliates. This request will not apply to the sharing of information about my transactions or experience with HIG (e.g. policy information, or payment history.) (Information about Vermont residents is not shared with Affiliates.) Sharing with Non-Affiliates: I do not want my non-public personal information (e.g. name and address) shared with Non-Affiliates. I understand that this may exclude me from receiving valuable offers. This request will not apply to the sharing of information that is permitted by law. (Information about California and Vermont residents is not shared with Non-Affiliates.) Limiting Marketing by Affiliates: I do not want your Affiliates to use my personal information for marketing purposes. My policy number is: _____________________________ Please print clearly Name (as it appears on your policy) Address City State (____) Phone Number Please allow sufficient time for us to process your opt-out request. Hig09 Zip