CONSENT in accordance with the Act Respecting the Protection of Personal Information
If it should be necessary for the purpose of my file, I specifically consent that my broker and my insurers, for the time required to fulfill their functions:
(A)Gather all the pertinent necessary information from the holders of my prior insurance files, intermediaries in the insurance industry, insurance companies, financial institutions, credit agencies, government records establishing driving experience, prevention, detection, or repression of crime agencies and institutions that gather and compile data on insurance risks and losses:
-- for the purpose of establishing the premium and the assessment of risk; and, -- for the purpose of verification, assessment and the settlement of losses;
Furthermore, I authorize my broker to sign on my behalf any request or form that may be necessary in order to gather information concerning me.
(B) Disclose, in the case of my broker, the information obtained to insurers with whom he is doing business; when it is my insurers, to institutions that gather and compile data on insurance risks and losses and prevention, detection or repression crime agencies. Solely the employees, mandatories or representatives of my broker, insurers or of institutions referred to in this paragraph will have access to this information when required within the execution of their functions.
Furthermore, I consent that holders of information concerning me and covered by the present consent be released from their confidentiality undertaking and that they convey the required information to my broker, my insurers, their employees, trainees or representatives.
I acknowledge having been informed of my right to access to information obtained by virtue of the present consent and to have it corrected, if need be.
Furthermore, I acknowledge having been informed that I may address all questions regarding the present consent to my broker and/or my insurers, their employees, trainees or representatives.
This insurance application is considered to include all provisions for all forms to be issued in accordance with this contract. The total estimated policy premium is subject to an adjustment.
