PERSONAL INFORMATION MANAGEMENT
Desjardins Financial Security Life Assurance Company (DFS) handles the personal information it has on you in a confidential manner. DFS keeps this information on file so that you
may benefit from the Company’s various financial services (insurance, annuities, credit, etc.). This information is consulted solely by DFS employees who need to do so in the course
of their work.
You have the right to consult your file. You may also have information corrected if you demonstrate that it is inaccurate, incomplete, ambiguous or not useful. To do so, you must
send a written request to the following address: Privacy Officer, Desjardins Financial Security Life Assurance Company, 200, rue des Commandeurs, Lévis, Québec, G6V 6R2.
DFS may use the client list to offer its clients an insurance product following the termination of their group insurance. If you do not wish to receive these offers, you may have your
name removed from the list. To do so, you must send a written request to the Privacy Officer at DFS.
DFS uses service providers located outside of Canada to perform certain specific activities in its normal course of business. As such, it is possible that some of your personal
information may be transferred to another country and be subject to the laws of that country. For information about DFS's policies and practices in terms of transferring personal
information outside of Canada, visit the DFS website at www.dsf-dfs.com, or write to the DFS Privacy Officer at the address indicated above. The Privacy Officer can also answer
any questions you may have about the transfer of personal information to service providers located outside of Canada.
NOTICE APPLICABLE TO MIB, INC.
Information regarding the insurability of the person to be insured will be treated as confidential by Desjardins Financial Security Life Assurance Company (DFS), its reinsurers
and MIB, Inc., a non-profit membership organization of insurance companies that operates an information exchange on behalf of its members. If you submit an application for life
or health insurance coverage for an individual or a benefit claim for an insured to another MIB, Inc. member company, upon request, MIB, Inc. will supply such company with the
information it has on file about this person. MIB, Inc. receives personal information for which the collection, use and disclosure is governed by the Personal Information Protection
and Electronic Documents Act (PIPEDA) and provincial laws. Accordingly, MIB, Inc. has agreed to protect such information in a manner that is substantially similar to DFS’s privacy
and personal information protection practices and in accordance with applicable laws. As a U.S.-based company, MIB, Inc. is also bound by U.S. laws regarding the disclosure
of personal information. If you have any questions about MIB, Inc.’s commitment to ensuring the confidentiality of insureds’ personal information, contact the MIB, Inc. Privacy
Department at privacy@mib.com. Upon request, MIB, Inc. will disclose all of the information in an insured’s file to that insured. Insureds can contact MIB, Inc. at 416 597-0590.
Insureds who dispute the accuracy of the information MIB, Inc. has on record for them can seek a correction in accordance with the procedures set forth on MIB, Inc.’s Website
at www.mib.com. They can also write to MIB, Inc.’s information office at 330 University Avenue, Suite 501, Toronto, Ontario M5G 1R7. DFS and its reinsurers can also release
information from their files to other insurance companies to which an application for life or health insurance or a benefit claim has been submitted. Consumers can obtain additional
information about MIB, Inc. at www.mib.com.
DECLARATION AND AUTHORIZATION TO COLLECT AND COMMUNICATE PERSONAL INFORMATION
For the sole purpose of determining insurability, managing files and processing claims, I authorize Desjardins Financial Security Life Assurance Company (DFS) or its reinsurers:
a) to collect from any individual, legal entity or public or parapublic organization only the personal information they have about me that is needed to process my file. This information
may be collected from third parties, including any health care professional or establishment, MIB, Inc., insurance and reinsurance companies, personal information brokers,
investigation firms, the contract holder, my employer or my former employers; b) to disclose to those individuals, legal entities or public or parapublic organizations only the personal
information they have about me that is needed to manage my file; c) to request, if applicable, an investigation report about me and to use the personal information contained in other
files it may have that are now closed; d) to disclose to my personal physician any medical information about me that was obtained during the evaluation of my file; e) to disclose
to other insurers or reinsurers any information about me that is relevant to determining my eligibility for insurance or for benefits; f) to provide a brief report of my personal health
information to MIB, Inc. This authorization also applies to the collection, use and communication of personal information regarding my dependents, insofar as applicable to my
claim. A photocopy of this authorization is as valid as the original. I hereby certify that the answers given above are complete and true. I agree that they form an integral part of my
application for insurance. I hereby acknowledge that I have read the Personal Information Management section, as well as the notice regarding the MIB, Inc. and that I have received
a copy thereof. The insurance will become effective on the date indicated on the contract. Any false declaration may result in the cancellation of the insurance. If for medical
reasons my application for insurance is not accepted as it was submitted, I authorize the medical director to provide the reason for such a decision to my physician.
THE PARTICIPANT MUST RETURN THE ORIGINAL TO DESJARDINS FINANCIAL SECURITY LIFE ASSURANCE COMPANY ALONG WITH HIS APPLICATION AND KEEP A COPY FOR HIS RECORDS.
PARTICIPANT SPOUSE CHILDREN
Any other treatment
If yes, please specify
Yes No Yes No Yes No Yes No
Date
Date First name
Date
First name
Date
Please provide details for any
affirmative answer to question 2,
including: diagnosis, treatment,
duration, result.
First name First name
AUTHORIZATION TO COLLECT AND COMMUNICATE PERSONAL INFORMATION
For the sole purpose of determining insurability, managing files and processing claims, I authorize Desjardins Financial Security Life Assurance Company (DFS) or its reinsurers:
a) to collect from any individual, legal entity or public or parapublic organization only the personal information they have about me that is needed to process my file. This information
may be collected from third parties, including any health care professional or establishment, MIB, Inc., insurance and reinsurance companies, personal information brokers,
investigation firms, the contract holder, my employer or my former employers; b) to disclose to those individuals, legal entities or public or parapublic organizations only the personal
information they have about me that is needed to manage my file; c) to request, if applicable, an investigation report about me and to use the personal information contained in other
files it may have that are now closed; d) to disclose to my personal physician any medical information about me that was obtained during the evaluation of my file; e) to disclose
to other insurers or reinsurers any information about me that is relevant to determining my eligibility for insurance or for benefits; f) to provide a brief report of my personal health
information to MIB, Inc. This authorization also applies to the collection, use and communication of personal information regarding my dependents, insofar as applicable to my claim.
A photocopy of this authorization is as valid as the original.
Name and address of physician
Signature of participant Signature of spouse Signature of witness Date
Signature of dependent children aged 16 and
over to be insured (aged 14 and over for Québec)
Signature of participant Signature of spouse Signature of witness
Date
Signature of dependent children aged 16 and
over to be insured (aged 14 and over for Québec)
