APPLICATION FOR REINSTATEMENT AND/OR CHANGE
REINSTATEMENT/CHANGE 07/2017 Customer Copy 1 of 2
NOTICES & DISCLOSURE STATEMENTS
CUSTOMER COPIES
NOTICE OF MEDICAL INFORMATION BUREAU, INC. (MIB, Inc.)
Information regarding your insurability will be treated as confidential. We, or our reinsurers may, however, make a brief report
thereon to the MIB, Inc., a non-profit membership organization of insurance companies which operates an information exchange
on behalf of its members. If you apply to another MIB, Inc. member company for life and health insurance coverage, or a claim for
benefits is submitted to such a company, MIB, Inc., upon request, will supply such company with the information it may have in its
file.
Upon receipt of a request from you, MIB, Inc. will arrange disclosure of any information it may have in your file. If you question the
accuracy of information in MIB, Inc.’s file, you may contact MIB, Inc. and seek a correction in accordance with the procedures set
forth in the federal Fair Credit Reporting Act. The address of MIB, Inc.’s information office is 330 University Avenue, Suite 501,
Toronto, ON M5G 1R7, telephone number (416) 597-0590.
We, or our reinsurers, may also release information in our file to other life insurance companies to whom you may apply for life and
health insurance, or to whom a claim for benefits may be submitted.
NOTICE OF INVESTIGATIVE REPORTS
In the processing of the application for reinstatement/change, The Wawanesa Life Insurance Company may obtain Motor Vehicle
Driving abstract/records, a personal investigation or consumer reports containing personal information about the individuals
proposed for insurance.
NOTICE OF CONSENT TO RELEASE MEDICAL/UNDERWRITING INFORMATION
As part of the underwriting process, the Medical Director of Wawanesa may need to release medically related information obtained
during the underwriting process to your personal physician or other medical practitioner. We may also need to disclose information
regarding the underwriting factors to your Wawanesa Life independent insurance broker.
NOTICE OF CONSENT & DISCLOSURE REGARDING PERSONAL INFORMATION
We collect, use and disclose your personal information in order to administer the products and services you have requested.
Personal Information is collected for the purposes of: establishing and maintaining communications with you; underwriting risks on
a prudent basis; investigating and paying claims; receiving payments of insurance premiums and policy loan repayments;
withdrawing premiums from and depositing funds into your account (applicable if PAD Agreement is signed); detecting and
preventing fraud; offering and providing products and services to meet your needs; compiling statistics and acting as required or
authorized by law.
We may share your personal information with the following people, organizations and service providers: Wawanesa Life employees
and independent insurance brokers who require this information to perform their jobs; third party providers who require this
information to provide their services to you, which may include paramedical agencies, underwriters, claims investigators,
investigative agencies, providers of information processing and storage, programming, printing, mailing and distribution services;
applicable reinsurance companies to allow them to evaluate and administer any insurance risk that the accept; the Medical
Information Bureau Inc. (MIB, Inc.) as explained the notice provided; people to whom you have granted access; and people who
are legally authorized to view your personal information. These people, organizations and service providers may be in other
provinces or in jurisdictions outside Canada. Your information may be shared as required by the laws of those jurisdictions.
There are other situations where we may share aspects of your personal information with others, as described below:
We may share medical information collected about you with your doctor.
We may share your personal information with an organization or person from whom we are collecting information about you,
but only as required to obtain the information needed.
If laboratory tests performed on our behalf show that you have tested positive for infectious diseases such as HIV or
hepatitis, we may report this information to the appropriate public health authorities, as required.
Because the medical information you include in this application becomes part of the printed contract, in the case of a corporate or
joint policy, your medical information may be included in the policy contract issued to the policy owner(s) and any subsequent
owners.
In order to provide services to you in the future and provide you with the benefits included in the policy, Wawanesa Life may need
to collect, use and disclose additional personal information about you. We may not require you to provide consent at that time.
Any restriction or withdrawal of your consent may result in Wawanesa Life being unable to provide you with the product or service
being applied for or having to terminate the policy.
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: Senior Vice President,
Chief Legal Officer & Corporate Secretary, The Wawanesa Life Insurance Company, 900-191 Broadway, Winnipeg, Manitoba
R3C 3P1.
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