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? *

Yes
No

Company

Full Name of the Point of Contact *

Correspondence Address *

Postcode *

Telephone Number

Email Address

What is your relationship with the data subject?

Why are you making this request for information on their behalf?

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.

Title

Full Name *

Current Address *

Postcode *

Telephone Number

Email Address

Date of Birth

Previous Name(s) (if any)

Previous Address (if at current address for less than 2 years)

Section 3 – Details of the Request

Case Reference ID

Please specify the processing types for which you would like to withdraw consent

Please provide any relevant information that will help us identify and specifically locate your personal data

Section 4 – Declaration (Mandatory)

Enclosed Documents (PDF files only)

I am the data subject / authorised by the data subject named above and hereby request under the provisions of the GDPR that QBE EO do not use my personal data for the specific processing mentioned in Section 3 of this form. I have enclosed all the required documents as stated in Section 1 above and hereby confirm that all the information supplied in this form is accurate to the best of my knowledge. *

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