Individual Rights Request Form

Individual Rights Request Form State Privacy Laws

This form is to be used by individuals exercising individual rights afforded them under certain state laws regarding information Mercer[1] holds about them. These individual rights are described in detail in Mercer’s Privacy Notice and may vary from state to state.

If you are a current, former, or prospective employee of Mercer, please submit your request here .

Depending on the relevant state law, this form may be completed and submitted by the individual themselves, by a parent or guardian on behalf of a minor child, or by a third party authorized to submit the request on behalf of an individual. If you are requesting your own personal information you will be required to verify your identity. If requesting personal information on behalf of another individual as permitted under relevant state law, you will be required to verify both the identity of that individual as well as your own, and to submit verification of your authority to request personal information on the individual’s behalf, whether as parent, guardian or other authorized party as applicable.

[1] Mercer refers to Mercer (US) Inc. and its affiliates.

By proceeding you acknowledge that your data will be processed in accordance with our Privacy Notice.

Section - 1 About The Individual

Individual Information

Last Name

First Name

Maiden/Former Last Name

Date of Birth

Current Street Address

Current City

Current State

Current Zip Code

Current E-mail Address

Current Daytime Telephone Number

Preferred Method of Contact (to further support request fulfilment)

Previous Information

If the consumer would have been known to Mercer by a different name, or at a different address during the period to which the information relates, please state the name(s) and address(es) below:

Previous Information 1

Name 1

Home Address (including Zip Code)

From

Previous Information 2

Name 2

Home Address (including Zip Code)

From

Non Consumer

Submission Email Id

Business Email Id

Please check the appropriate box below if, as permitted under relevant state law, anyone other than the Individual is filling out this form.

Parent/Legal Guardian

Legal Representative

If the request is made on behalf of the individual by a parent or guardian, please provide:

* Required only if checked Parent/Guardian above

Last Name

First Name

Maiden/Former Last Name

Date Of Birth

Home Address (including Zip Code)

Daytime Telephone Number

Preferred Method of Contact (to further support request fulfilment)

If the request is made on behalf of the individual by a legal representative please provide:

*Required only if checked Legal Representative above

Last Name

First Name

Type of Legal Representation

Current Address (including Zip Code)

DayTime Telephone Number

Preferred Method of Contact (to further support request fulfilment)Preferred Method of Contact (to further support request fulfilment)

Section - 2 About The Request

Please select the appropriate product

Pavilion

Other

Select the privacy rights the Individual is seeking to exercise by checking the appropriate box:

Deletion: Request Mercer to delete the consumer’s personal information from Mercer’s records.

Disclosure/Access: Request access to personal information about the consumer that Mercer has collected.

Correction: Request Mercer to correct outdated or incorrect personal information, but not delete.

Appeal: Request to appeal Mercer’s denial of an individual right’s request.

Opt-Out: Request to opt-out of the sale of their personal information.

Appeal: Request to appeal Mercer’s denial of an individual right’s request.

Opt-Out: Request to opt-out of the sale of their personal information.

Please use the space below to provide further details that may help to locate the information sought. For example, specific documents or information that you are seeking, the Company Name of your Employer who has the direct relationship with Mercer or the name or type of product/service the individual participates(d)

Section - 3 How Applications Are Processed

Mercer may not provide you with information where an applicable exemption is available. In the event we are unable to identify any data that relates to you or are unable to appropriately verify your individual identify via the verification documents submitted, you will be contacted by a Mercer representative.

The information requested will be supplied in an electronic format sent to the email address provided above for the requesting party (Individual, parent/guardian or legal representative).

Please check here for an exception request - paper delivery

The information contained within the request is accurate, and the person completing the form is authorized to make this request.