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.

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.

Prior to submitting the request, the consumer it’s guardian or representative will be required to acknowledge they have read the Privacy Notice.

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

Section - 1 About The Consumer

Consumer Information

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 

Previous Information 2

Non Consumer

Please indicate the nature of the consumer’s relationship with Mercer

If the consumer is an employee of Mercer (current or former), please provide the following employment information:

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

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

* Required only if checked Parent/Guardian above

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

*Required only if checked Legal Representative above

Section - 2 About The Request

Please select the Line of Business/Product Portfolio(s) to which the request applies by checking the appropriate box(es)

Health and Benefits

Examples include:

  • Medical, Dental, Life Insurance
  • Flexible Spending Accounts
  • Supplemental Coverages, e.g., Pet Insurance
  • Post-Retirement Medical Plans

Wealth and Investments

Examples include:

  • Retirement/Savings Plans
  • Investment Plan/Stock Purchase Plans

Workforce and Careers

Examples Include:

  • Talent Strategy & Mobility
  • HR Transformation
  • Workforce Rewards
  • Workday Services

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

      Opt-In: Please contact your appropriate product provider.

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 consumer participates(d)

Section - 3 How Applications Are Processed

Requests will not be accepted or processed unless completed correctly with all requested information being supplied.

Mercer may not provide you with information where an applicable exemption is available.

Mercer will inform you if we are unable to identify any data that relates to the consumer or otherwise unable to process the request.

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