CONSENT TO COLLECT, USE AND
DISCLOSE PERSONAL INFORMATI
O
N
(ACCIDENT AND SICKNESS CLAIMS)
Consent to Collect A&S (02.2012)
I authorize SSQ Insurance Company Inc. and its authorized representatives to collect, use, and disclose personal information about me
and, where applicable, my dependent children as permitted by law from and to the following persons and organizations:
any licensed medical practitioner or licensed health professional, hospital, clinic or medically related facility;
any other insurance company or financial institution, including any reinsurance company;
any other person or organization with information relevant to my claim; and
any person or organization that provides information services or insurance services to, or that acts as insurance intermediary for
SSQ Insurance Company Inc.;
for the following purposes:
establishing and maintaining communications with me;
underwriting group risks on a prudent basis;
investigating and settling claims;
detecting and preventing fraud;
offering and providing products and services to meet my needs;
compiling insurance statistics; and
complying with the law.
The personal information collected by SSQ Insurance Company Inc. will be entered into a file whose subject is accident and sickness
insurance. The file will be kept at SSQ Insurance Company Inc. offices. Within SSQ Insurance Company Inc., this file will only be
accessed by those employees who require access in order to fulfill the purposes listed above. I understand that I may access my personal
information contained in this file and correct such information if necessary by directing a written request to:
Privacy Officer
SSQ Insurance Company Inc.
2020, University Street
Suite 1800
Montreal, Quebec H3A 2A5
This consent shall be valid for the length of time necessary for SSQ Insurance Company Inc. to achieve the purposes listed above. I may
withdraw this consent at any time by giving SSQ Insurance Company Inc. written notice of withdrawal. I understand that withdrawal of my
consent might result in SSQ Insurance Company Inc. being unable to provide me with a product or service.
A copy of this consent shall be considered as effective and valid as the original.
POLICY NO.
DATE OF THE OCCURENCE
DD / MM / YYYY
CAUSE (ACCIDENT, ILLNESS, ETC.)
SIGNATURE OF INSURED
X
DATE OF SIGNATURE
DD / MM / YYYY
PRINT NAME OF INSURED TELEPHONE NUMBER
ADDRESS
Where the claim is for the Accidental Death of the Insured Person, this consent must be signed by their authorized
representative, and shall apply to both the Insured Person and the authorized representative:
SIGNATURE OF AUTHORIZED REPRESENTATIVE
X
DATE OF SIGNATURE
DD / MM / YYYY
PRINT NAME OF AUTHORIZED REPRESENTATIVE RELATIONSHIP TO THE INSURED
The completed authorization can be returned to SSQ Insurance Company Inc. at any of the following addresses:
Exchange Tower, 130 King Street West, 23rd floor, Suite 2350, PO Box 160, Toronto, Ontario M5X 1C7
2020 University Street, Suite 1800, Montreal, Quebec H3A 2A5
220 – 12th Avenue S.W., Suite 600, Calgary, Alberta T2R 0E9
