CONSENT TO COLLECT, USE AND DISCLOSE CLIENT PERSONAL INFORMATION FOR THE PURPOSES OF INSURANCE AND FINANCIAL SERVICES brokered through  Dodgson & Schaufelberger Insurance Brokers Ltd

By this consent, I, _________________________________ ("the Client") hereby confirm that I wish to acquire or renew a policy or policies of insurance and authorize Dodgson & Schaufelberger Insurance Brokers Ltd. to act as my insurance broker. 

A Broker’s Professional Duty of Confidentiality

As professional brokers we are committed to holding our clients personal information in strict confidence, and we shall not disclose any such information unless authorized by our clients, required by law to do so or required to do so in conducting negotiations with underwriters or insurers on behalf of the client.

Collection, use and Disclosure of Personal Information  

We or any insurer, to whom we submit your application may collect, use and disclose personal information from you and about you for the following purposes:

a) To understand your needs for insurance products we sell or administer.
b) To analyze the suitability of our insurance products and financial services for you.
c) To determine your eligibility for our products and services.
d) To set up, manage and offer products and services that you may not have now with us. (Ex Umbrella Liability, Disability or Life Insurance)
e) To provide you with ongoing service including disclosure for competitive quoting.
f) To meet our legal and regulatory requirements.
g) To facilitate underwriting your insurable risks and assistance with insurance claims.

Withdrawal of Consent

You may generally withdraw your consent at any time. If you refuse or withdraw your consent to the collection, use or disclosure of information about you, we may not be able to provide or continue to provide you with some products, services or information of value to you. 

Accuracy

All information which you give us at any time will be true and complete and you will not withhold any material information. If any personal information changes or becomes inaccurate or out of date, you will tell us so we can revise our records.   

Acknowledgement

I acknowledge that I have read the information set out on this form, and I hereby consent to the Broker's collection, use and disclosure of my personal information in the manner and for the purposes set out above.

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Signature                    

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Date

Brokerage Privacy Officer