CHANGE OF ADDRESS
ADDRESS CHANGE 06 2018
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Wawanesa Life and the tree logo are registered trade-marks of The Wawanesa Mutual Insurance Company and used under license by The Wawanesa Life Insurance Company.
POLICY NUMBER(S) NAME OF LIFE INSURED or ANNUITANT
PREVIOUS ADDRESS
Number and Street
City and Province Postal Code
NEW ADDRESS
Effective Date:
Day Month Year
Number and Street
City and Province Postal Code
-
Phone Number Email
CONSENT & DISCLOSURE REGARDING PERSONAL INFORMATION
I consent to Wawanesa Life collecting, using and disclosing my personal information for the purposes of: establishing and maintaining
communications with me; investigating and paying claims; detecting and preventing fraud; offering and providing products and services to
meet my needs; compiling statistics and acting as required or authorized by law.
I understand that Wawanesa Life may share my personal information with the following people, organizations and service providers:
Wawanesa Life employees and agents who require this information to perform their jobs; providers of information processing and
storage, programming, printing, mailing and distribution services; people to whom I have granted access; and people who are legally
authorized to view my personal information. These people, organizations and service providers may be in other provinces or in
jurisdictions outside Canada. My information may be shared as required by the laws of those jurisdictions.
You can obtain further information about Wawanesa Life's Personal Information Protection Policy and practices concerning service
providers outside Canada from the Wawanesa Life Executive Office at 400-200 Main Street, Winnipeg, MB R3C 1A8 or at
www.wawanesalife.com.
If you have a question (including a question concerning our collection of personal information, or the collection, use, disclosure or storage
of personal information by service providers outside Canada on our behalf) or complaint regarding our privacy policies or procedures,
please contact the individual accountable for our personal information protection compliance: Privacy Officer, The Wawanesa Life
Insurance Company, 400-200 Main Street, Winnipeg, Manitoba R3C 1A8.
SIGNATURES
I confirm that I have read, understood and accepted the terms and conditions contained in the Consent & Disclosure Regarding Personal
Information.
A photocopy or an electronic reproduction of this document will be as valid as the original.
__________________________________ _____________________________________________
Date Signature of Policy Owner(s)
PLEASE RETURN FORM TO: The Wawanesa Life Insurance Company, 400-200 Main Street, Winnipeg, MB R3C 1A8
Should you have any questions or need assistance, please contact our Customer Service Department:
PHONE 1-800-263-6785 FAX 1-888-985-3872 EMAIL lifecustserv@wawanesa.com
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