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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.



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)
Use Ctrl/Cmd+click to select multiple files