Rectification Request Form

Request to Rectify Personal Data Under Article 16 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)

Is/Was the data subject a QBE employee? *

Yes
No

If you have selected ‘Yes’ to the previous question, please also provide the following details:

NI Number *

Employee ID

Section 3 – Details of the Request

Case Reference ID

Please specify the data discrepancy that needs rectification, including the documentation / records that contain the inaccurate / incomplete data, if known

Please provide the updated / corrected data that you require us to use going forward

Please provide an appropriate justification / reason to request that the specified data be rectified

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 rectify the personal data, as specified 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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