MomentousLogo
California Consumer Privacy Act Request

Thank you for your interest in Momentous Insurance Brokerage, Inc. We know that the information you provide to us to service your insurance needs is valuable to you and needs to be protected. We have taken great measures to protect that information both physically, procedurally and electronically to make sure that information does not get into the wrong hands.

If you would like to make a CCPA request, you must complete the form below and provide the information requested to us. Or, you may also make a CCPA request by calling our toll-free response number at 888-933-3938. Once you complete this form or call the toll-free number, we will then verify that the person making the request is the same person whose information has been requested by matching the information you provide below to the information we have on file. If we cannot verify this request, we will be unable to respond to your request.

Please note: we have not and will not collect any Personal Information from you that we are not also required to maintain under the insurance code as part of our insurance files. Therefore, we cannot lawfully delete any information that you have provided to us.

In completing the information below, please choose one of the two options applicable:


First Name *
Last Name *
Phone Number *
Email Address *
Account Name *
State of Residence *
Type of Request *

IF YOU ARE NOT A CLIENT OF MOMENTOUS INSURANCE BROKERAGE, INC., PLEASE PROVIDE ANY DETAILS OF YOUR INTERACTION WITH MOMENTOUS INSURANCE BROKERAGE, INC. THAT WILL HELP US IDENTIFY THE PERSONAL INFORMATION WE HAVE ABOUT YOU, SUCH AS, WHEN YOU COMPLETED THE ONLINE FORM TO REQUEST A QUOTE FOR INSURANCE COVERAGE, IN THE BOX BELOW.

Notes / Additional Information (Max: 200 characters)
Your CCPA Request was Submitted

We will review your request and reach out to you through the contact information you have provided.

Reference ID:

Thank you

Confirm Your Application

Would you like to submit your application?