Authorization for the collection
and release of personal information
to third parties
Please complete and mail this form to:
Dispute Resolution Officer
Desjardins Financial Security
200, rue des Commandeurs
Lévis (Québec) G6V 6R2
I authorize the Dispute Resolution Officer of Desjardins Financial Security Life Assurance Company and its representatives
to disclose all personal or confidential information that they have about me to
(Please print the name, address and phone number of the person representing you.)
pursuant to the review of my complaint filed on
(date)
concerning
(Briefly explain your complaint.)
It is understood that I also authorize
(name of the person representing you)
to disclose
all personal or confidential information concerning me to the Dispute Resolution Officer and his representatives as part of
the review of this complaint.
This authorization is valid from the day it is signed and until the Dispute Resolution Officer makes the final decision
regarding this complaint.
A photocopy of this authorization is as valid as the original.
Signed at , on / /
(city) (day) (month) (year)
Name of the insured: Signature of the insured:
(Please print.)
Address: Date of birth: / /
(day) (month) (year)
Telephone:
Witness:
(Please print.) (signature)
Desjardins Insurance refers to Desjardins Financial Security Life Assurance Company.
15399E
