The information on this form will be kept confidential and will not be released to any enforcement bureau or 3rd party unless you specifically request we do so. The American Policyholder Association will use your report to compile statistics of insurer misconduct. At the end of this form you will be given the choice to have us submit it for you to the appropriate Enforcement/Regulatory Agency or to use your incident only for statistical purposes and your report will be kept strictly confidential. In either case, the APA does not share your personal information except at your request.