PERSONAL INFORMATION CONSENT FORM
As part of the application for new or renewal insurance coverage(s), the Client hereby authorizes the Broker to collect, use and disclose personal information of such insured individuals as required and as permitted pursuant to relevant privacy laws or other laws.
The Client hereby expressly consents to the Broker collecting, using or disclosing personal information of such insured individuals, or providing such personal information to third parties as required, including insurance companies. Where there are insured individuals in addition to the Client, or where the Client is a commercial or other entity, the Client hereby covenants and warrants that the Client has obtained the appropriate consent from all of the insured individuals to disclose their personal information to the Broker for these purposes.
I understand that if at any time I wish to review and/or obtain my personal information, or restrict the general nature of this consent to any specific area, from Jones DesLauriers Insurance Management Inc. I may make a written request to do so. I may also request a copy of their privacy policies, make other enquiries, express concerns or file a complaint by contacting Jones DesLauriers Insurance Management Inc.’s Privacy Officer. The Privacy Officer at Jones DesLauriers Insurance Management Inc. is:
Mark Watson, Partner, Vice President Claims
Jones DesLauriers Insurance Management Inc.