Important Notice for New York Victims of Domestic Violence and Endangered Individuals
 

American National Life Insurance Company of New York
Farm Family Casualty Insurance Company
Garden State Life Insurance Company
United Farm Family Insurance Company
(each and together the “Company,” “we,” or “us”)

New York Insurance Law § 2612 and Insurance Regulation 168 govern confidentiality protocols for victims of domestic violence and endangered individuals.

A person covered by an insurance policy issued to another person, or a person covered by a group insurance policy, has the right to limit the disclosure of certain information and designate alternative contact information if the person delivers to the insurance company:

• a valid protection order against the policyholder; or
• a request to designate alternative contact information stating that disclosure of claim related information could endanger the person. 

Upon receiving the valid protection order or request to designate alternative contact information, the insurance company is prohibited from disclosing to the policyholder or other person covered by the group insurance policy:

• the address, telephone number, or other method of contact for the insured, or for any person or entity providing covered services to the insured;
• any personally identifiable information of the insured; 
• the nature of the covered services provided to the insured; or
• claim related information to any mailing address, telephone number, or other method of contact other than as designated in the request. 

This prohibition will remain in place for the duration of the protection order or until the request designating alternative contact information is cancelled by the requesting person in writing. 

If a child is the person covered by the insurance policy, this right may be asserted by and extends to the parent or guardian of the child. For your reference, “claim related information” means all claim or billing information relating specifically to the person covered by the insurance policy.

Procedures to Submit a Valid Protection Order or Request to Designate Alternative Contact Information

To limit the disclosure of certain information and designate alternative contact information, you may submit either:

• a copy of your valid protection order; or
• a request to designate alternative contact information by completing the confidential communications form.

To download and access the confidential communications form, please click the link below. 

American National requires a request to designate alternative contact information to:

• be in writing; 
• state that the disclosure of all or part of the claim related information could endanger the insured; and
• specify an alternative mailing address, telephone number or other method of contact. 

You may submit a copy of your valid protection order or your completed confidential communications form to American National by:

• Contacting us at (877) 662-6722;
• Sending an email to PrivacyCompliance@AmericanNational.com; or
• Mailing a written request to:
      Privacy Compliance
      PO Box 1896
      Galveston, Texas 77553-9902

The limitations will remain in place for the duration of the protective order or until you submit a written request to cancel your designation of alternative contact information at the email address or mailing address listed above. 

For additional help, you may also want to contact the New York State Domestic and Sexual Violence Hotline at 1-800-942-6906

This form is for use by a person who is covered by a policy of insurance issued in the state of New York by American National Life Insurance Company of New York, Farm Family Casualty Insurance Company, Garden State Life Insurance Company, or United Farm Family Insurance Company and wishes to make a reasonable request to limit the disclosure of certain information and to designate alternative contact information.