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QBE Re

Withdrawal of Consent Form

Right to Withdraw Consent under Article 7 of the General Data Protection Regulation (GDPR)

Section 1 – Requestor Details

- This section includes details of the individual / company submitting this request.
- All fields marked as * are mandatory.

Are you the Data Subject? *

If you are the data subject, please enclose evidence of your identity with this form. Acceptable forms of identity are copies of either 1) driving licence; 2) passport; or 3) birth certificate

If you are acting on behalf of the data subject, please enclose their written authority with this form together with evidence of their identity i.e. copies of either their 1) driving licence; 2) passport; or 3) birth certificate. Please also provide the declaration set out in Section 4 of this form, typed on your company letterhead and signed, as evidence of your identity.

Section 2 – Data Subject Details

- This section includes details of the individual whose personal data is requested
- A separate form must be completed for each data subject
- All fields marked as * are mandatory.

Section 3 – Details of the Request
Case Reference ID is the number that may have been provided to you in the email along with link to this form
(e.g. Claims number, policy number, date and location of loss/incident, complaints reference number, name of the related department or point of contact within QBE, purpose or dates of any dealings the data subject might have had with QBE EO in the past, etc.)
Section 4 – Declaration (Mandatory)
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