Consumer Data Access Requests

Notice to Consumers


The information provided sets the policy adopted by CBC Benefit & Insurance Services (aka Custom Benefit Consultants, Inc.) for responding to “consumer data access requests” (CDAR’S) as applicable under certain State and Federal consumer protection legislation.  CBC Benefit & Insurance Services will respond to all consumer data access requests consistent with applicable Federal law and the State law that applies to the requester’s current state residency at the time of request.


A consumer data access request is a written request for personal information (known as personal data) held about you by CBC Benefit & Insurance Services.  Consumer protection legislation gives individuals the right to know what information is held about them. However, this right is subject to certain exemptions.

When we receive a consumer data access request we will first check that we have enough information to be sure of your identity. Often we will have no reason to doubt a person’s identity, for example, if we have regularly corresponded with them. However, if we have good cause to doubt your identity we can ask you to provide any evidence we reasonably need to confirm your identity.


We will gather any manual or electronically held information and identify any information provided by a third party or which identifies a third party.


If we have identified information that relates to third parties, we will write to them asking whether there is any reason why this information should not be disclosed. We do not have to supply the information to you unless the other party has provided their consent or it is reasonable to do so without their consent. If the third party objects to the information being disclosed we may seek legal advice on reasonable actions to fulfill your request.


We will deal with your consumer data access request without undue delay and in within 30 days of receipt of your request. However, if the work involved is particularly complex or if numerous requests are made then we may extend this period by up to an additional 60 days. In this case, we will inform you about the extension and explain the reasons.


We will not charge a fee for dealing with your request unless it is manifestly unfounded or excessive or if you are requesting paper copies in which case mailing and shipping costs will apply and be charged in advance of information release. If we charge a fee, we will inform you of this and explain the reasons for doing so.  Certain state and federal laws govern the amount of consumer data access requests can be made be made per individual annually and what charges can be applied to processing.


We will explain what steps have been taken in dealing with your request i.e. we will set out the source of your personal information we have gathered. The information will be provided in a concise, transparent and easily accessible form.  Information will be provided in a convenient electronic format, or by other means, when necessary.


There are a number of exemptions to our duty to disclose personal data and we may seek legal advice if we consider that they might apply. An example of an exemption is information covered by legal professional privilege or law enforcement requirements.


If we agree that the information is inaccurate, we will correct it and where practicable, destroy the inaccurate information. If we do not agree or feel unable to decide whether the information is inaccurate, we will make a note of the alleged error and keep this on file. If you are not satisfied by our actions, you can seek recourse through our internal complaints procedure.


The CBC Benefit & Insurance Services Data Protection Coordinator can be contacted at:


Brandon Russell – Data Protection Coordinator
300 S. Fourth St., Ste. 700
Las Vegas, NV 89101
Phone: 800.309.9029





You should complete this form if you want us to assist you with an information request under HIPAA or certain state legislation as it pertains to personal data held and/or used by CBC Benefit & Insurance Services or Custom Benefit Consultants, Inc (further: “Company”). You are currently entitled to receive this information under as applicable with U.S. State and Federal Laws.  


We will endeavor to respond promptly and in any event within 30 days of the latest of the following:


  • Our receipt of your written request; or
  • Our receipt of any further information we may ask you to provide to enable us to comply with your request.


The information you supply in this form will only be used for the purposes of identifying the personal data you are requesting and responding to your request. Requests for information covered under any state or federal legislation will only be accepted by written request, including the below form.  While this specific form is not required, providing the information as requested will likely result in more efficient processing of your request.


SECTION 1: Details of the person requesting information

Full Legal Name:

Street Address:







SECTION 2: Are you the data subject?


Please tick the appropriate box and read the instructions which follow it.


YES - I am the data subject.

(please go to section 4)


NO - I am acting on behalf of the data subject.

I understand that the Company reserves the right to validate both my identity and my authorization to act on behalf of the data subject by confirming directly with the data subject through a phone call with the subject, or another reasonable method.

(please go to section 3)


Prior to releasing any information, the Company will make every reasonable effort to validate the identity of the data subject, or the data subject’s delegate.  Identity validation will be conducted by way of a follow up phone call to the phone number we have on file for the data subject.  Data provided in this form will not be used for identity validation purposes.


If we are unable to validate identity to a reasonable level of comfort, we reserve the right to refuse to grant your request.  You are entitled to submit another request for information if your initial request is denied for any reason.


SECTION 3: Details of the data subject (if different from section 1)

Full Legal Name:

Street Address:








SECTION 4: What information are you seeking?


Please describe the information you are seeking. Please provide any relevant details you think will help us to identify the information you require.


Please note that if the information you request reveals details directly or indirectly about another person we will have to seek the consent of that person before we can provide that information. In certain circumstances, where disclosure would adversely affect the rights and freedoms of others, we may not be able to disclose the information to you, in which case you will be informed promptly and given full reasons for that decision.


While in most cases we will be happy to provide you with copies of the information you request, we nevertheless reserve the right, in accordance with certain State and Federal Laws, not to provide you with copies of information requested if to do so would take “disproportionate effort”, or in accordance with the Company’s right to charge a fee or refuse the request if it is considered to be “manifestly unfounded or excessive”. However we will make every effort to provide you with a satisfactory form of access or summary of information if suitable.



SECTION 5: Information about the collection and processing of data


If you want information about any of the following, please check the boxes:

What personal information the Company holds about you.
What personal information the Company collects about you.
Is my personal information being sold and to whom.
Request a change or amendment to your personal information
Restrict uses and disclosures for their personal information.


SECTION 6: Declaration


Please note that any attempt to mislead or illegally require the protected information of another individual may result in prosecution under applicable U.S. State and Federal Laws.


I confirm that I have read and understood the terms of this subject access form and certify that the information given in this application to the Company. is true. I understand that it is necessary for the Company to confirm my / the data subject’s identity and it may be necessary to obtain more detailed information in order to locate the correct personal data.


I understand that the Company will always err on the side of data privacy and personal protection, and that if I am unable to adequately validate my identity, or my right to receive or access the data I am requesting, it is possible that my request will be denied.










If you wish to fill out this form later, You may also download this printable version of this form and fax it to: 1.855.450.1188 or email the completed form to:


Company Data Protection Coordinator:



Correcting Information

If after you have received the information you have requested you believe that:


  • the information is inaccurate or out of date; or
  • we should no longer be holding that information; or
  • we are using your information for a purpose of which you were unaware;
  • we may have passed inaccurate information about you to someone else;
  • Then you should notify our Data Protection Coordinator at once.






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