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.

[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