2412 Kaladar Ave. Ottawa, Ontario K1V 8C1
Tel: (613) 526-1184 Fax: (613) 526-4974
info@trigoninsurance.com

Personal Information Client Consent Form

As part of my application for insurance, I hereby consent to the brokerage firm - (the "Broker") collecting, using and disclosing personal information required for purposes of considering my application for new or renewal property/casualty, automobile insurance coverage &/or life/disability, RRSP and mutual funds.

The Broker is authorized to collect, use, and disclose personal information and provide such personal information to third parties, as required, including insurance companies. The Broker may also be required or permitted to disclose such personal information pursuant to relevant privacy laws or other laws.

If I wish to review personal information pertaining to my application or policy maintained by the Broker, obtain copies of the Broker's privacy policies or standards, or make other enquires or express concerns, I understand that I may do so by contacting the Broker's Privacy Officer.

I agree that all personal information that I provide to the Broker will be complete and accurate.

Full Name: ______________________________

Signature: ______________________________

Date: ______________________________

Name of Brokerage: ______________________________

Brokerage's Privacy Officer: Joseph Ha