If request is for access to, or correction of, own personal information records:

Last name appearing on records: [   ] same as below, or: ________________________________________

[   ] Mr.      [   ] Mrs.       [   ] Ms.      [   ] Miss

Last Name:

First Name:

Middle Name:

Address: (Street/Apt. No./P.O. Box/R.R. No.)

City/Town:

Province:

Postal Code:

Telephone Number (Day):

(           ) ______________________________

Telephone Number (Evening):

(           ) ______________________________

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.

Preferred method of access to records:

[   ] Examine Original
[   ] Receive Copy

Signature:

Date:

For Brokerage Use Only

Date Received:

Request Number:

Comments:

Note: Your request will usually be processed within thirty days unless you are advised otherwise.

Please forward this document to:

Dodgson & Schaufelberger Insurance Brokers Ltd.

101 Cherryhill Blvd London ON N6H 4S4

Attention: Paul Dodgson, Privacy Officer