The client hereby acknowledges that the Broker has been retained by the Client to acquire or renew a policy or policies of insurance or to provide Consulting and/or Risk Management Services for the Client, under which the individual Client, or named individuals in addition to the Client, or where the Client is a commercial or other entity, its employees, servants, and representatives (hereafter collectively called “insured individuals” may be insured)

As part of the application for new or renewal insurance coverage(s), the Client hereby authorizes the Broker to collect, use and to disclose personal information of such insured individuals as required and as permitted to relevant privacy laws or other laws.

The client hereby expressly consents the Broker collecting, using or disclosing personal information of such insured individuals, or providing such personal information to third parties as required, including insurance companies. Where there are Insured Individuals in addition to the Client, or where the Client is a commercial or other entity, the Client hereby covenants and warrants that the Client has obtained the appropriate consent from all insured individuals to disclose their personal information to the Broker for these purposes accordingly.

If the client wishes to restrict the general nature of this consent to any specific area, please indicate:

If the client wishes:
• To review personal information maintained by the Broker pertaining to the Client’s application, policy or policies
• To obtain copies of the Broker’s privacy policies or standards; or
• To make other enquiries or to express concerns, the Client may do so by contacting the Broker’s Privacy Officer.

Broker’s Privacy Officer: Scott Sleightholm – 519-633-8448 x104 or

St. Thomas – 92 Centre Street, St. Thomas, ON, N5R 2Z5 – Fax: 519.633.4317
London – 5-360 Springbank Drive, London, ON, N6J 1G5 – Fax: 226.270.4060
Phone: 519.633.8448