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Note: An appeal must be sent in writing to the Federal Privacy Commissioner within six (6) months after the brokerage has given notice of its decision. Your Information (Circle One) Mr. Mrs. Ms. Miss SURNAME GIVEN NAME INITIALS NAME OF COMPANY ASSOCIATION OR ORGANIZATION ADDRESS UNIT CITY PROVINCE POSTAL CODE TELEPHONE If this appeal is not being made in a personal capacity, please provide the following information: NAME OF CONTACT TITLE TELEPHONE Representative Information (Complete only if you will be represented.) I authorize the following person to act on my behalf and to receive any personal information pertaining to me, as necessary for the purposes of this appeal. REPRESENTATIVE IS A: LAWYER AGENT SURNAME GIVEN NAME INITIALS NAME OF COMPANY ASSOCIATION OR ORGANIZATION ADDRESS UNIT CITY PROVINCE POSTAL CODE TELEPHONE Brokerage Information Dodgson & Schaufelberger Insurance Brokers Ltd 101 Cherryhill Blvd Suite 201 London ON N6H 4S4 NAME OF PRIVACY OFICER – Paul Dodgson Attachments The following documents have been attached (if available): Copy of the request. Copy of the brokerage’s decision letter. Details of the Appeal Please select the box (es) that explain why the appeal is being made. Deemed Refusal – It is more than 30 days since I made my request and I have not received a decision. Failure to Disclose Records – The institution decided to grant access to requested records but I have not received them. Time Extension – The institution decided to extend the time limit for responding to my request, and I disagree. No Jurisdiction – The institution indicated that the requested records are excluded from the Act and I disagree. Reasonable Search – The institution indicated that some or all of the requested records do not exist and I believe that more records do exist. Frivolous or Vexatious – The institution indicated my request is frivolous or vexatious and I disagree. Exemptions – The institution has exempted all or part of the requested records and I believe that more of them should be disclosed. Interim Decision – Because of the number of records at issue, the brokerage reviewed a sample of the records or consulted an experienced employee, and advised me of the exemptions that might apply, and provided me with a fee estimate. I disagree with the amount of the fee estimate. Fee/Fee Estimate – The brokerage sent me an access decision that included a fee or fee estimate that I feel is excessive. Fee Waiver – The brokerage has refused to grant my request to waive the fees. Refusal to Confirm or Deny – The brokerage has refused to confirm or deny the existence of the requested records. Correction – The brokerage has refused to make corrections to my personal information. Other – please explain: Resolution of Appeal Please describe how you feel this appeal could be resolved. Information about the Appeal Process For more information about the processes of the Information and Federal Privacy Commissioner/ and Code of Procedure for appeals, please contact the office of the Federal Privacy Commissioner at: Federal Privacy Commissioner Tel: 1-613-995-8210
This form and any additional documentation must be sent in writing to the Federal Privacy Commissioner no later then six months after the brokerage has given notice of its decision. |
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