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By submitting this completed form, I request that Primerica and its independent Representatives limit use and disclosure of personal information about me as described in "What Does Primerica Do With Your Personal Information" (PLA-111-15). You may also call toll free 1-800-770-0673, rather than submitting this form online. If you have previously requested we limit use of your information, you need not do so again.

Complete the *Required* fields below using your name as it appears on your Primerica product. These fields are necessary to properly identify your product in our system. The information in this form will be delivered to Primerica by secure transmission.

You may submit another form for any other name on your Primerica account(s), including any joint account holder.

First Name*:   
Middle Name:   
Last Name*:   
Street Address: Apt#:
State*: Zip Code*:
Account/Policy Number:
Regardless of how many products you own, please enter only one account or policy number.
Birth Date*:



Do not click SUBMIT until you have entered all required fields.
If you want to print this completed page, before you hit Submit, click "Print Page" above.