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

Personal Information Request Form

Please Note: A $ 50.00 application fee is required for most requests.

Client Name: ______________________________
Address: ______________________________
Telephone Number: ______________________________
Fax (if any): ______________________________
Email Address (if any): ______________________________

Insurer (if known): ______________________________
Policy Number (if known): ______________________________

I wish to file a request for:
Access to Own Personal Information
Correction to Own Personal Information

Detailed description of requested records, personal information or personal information to be corrected (If you are requesting access to or correction of your personal information, please identify the personal information that you would like access to, if known):

Note: If you are requesting a correction of personal information, please indicate the desired correction and, if appropriate, attach any supporting documentation. You will be notified if the correction is not made and you may require that a statement of disagreement be attached to your personal information.

__________________________  _____________________________ 
Signature of Client          Date Signed

Note: Your request will usually be processed within thirty days unless you are advised otherwise.
Please forward this document
To: Trigon Insurance Brokers Ltd., 2412 Kaladar Ave. Ottawa, Ontario K1V 8C1
Att: Joseph Ha, Privacy Officer

FOR OFFICE USE ONLY:
Date Received: ___________________________ By (Print Name): ______________________________
Date acknowledged: ___________________________ By (Print Name): ______________________________
Date of response: ___________________________ By (Print Name): ______________________________