Insurance companies and producers can use this form to report security breaches to our office.

Please use this form to submit a security breach notification to our office.

Note: Please DO NOT include personal health information, social security numbers or other confidential information. We will contact you if we need more information.

Indicates required field
Have you reported this breach to the U.S. Department of Health and Human Services?

Note: Please upload your reporting form or any confirmation documentation of your reporting to U.S. Department of Health and Human Services (www.hhs.gov).

Have you reported this breach to WA State Office of the Attorney General?

Note: Please upload your reporting form or any confirmation documentation of your reporting to WA State Office of the Attorney General (fortress.wa.gov).

Maximum 4 files.
20 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.