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7T002CF-0313 Underwritten by Co-operators Life Insurance Company. Property risks underwritten by The Sovereign General Insurance Company. CLAIM FORM –VISITORS TO CANADA SECTION 1: PRIVACY AND DECLARATION TIC Travel Insurance Coordinators Privacy Statement TIC is committed to protecting the privacy, confidentiality, accuracy and security of the personal information that it collects , uses, retains and discloses in the course of conducting business. At TIC, we recognize and respect the importance of privacy. When you enrol for insurance coverage or submit a claim, we establi sh a confidential file and collect, use and disclose your personal information for the purposes of issuing, administering, adjudicating and/or servici ng your insurance. You may access and correct, if needed, the personal information in your file by sending us a request in writing. We limit access to your personal information to our staff and other persons we have authorized who have a need to know it to pe rform their duties. Our systems and procedures are designed to prevent the loss, misuse, unauthorized access, disclosure, alteration, or destructio n of your information. Our commitment to security extends to the contracts and agreements we sign with external suppliers and service providers. We ma y store or process your personal information in Canada, the United States or other countries for processing, storage, analysis or disaster recover y and, under applicable law, governments, courts, law enforcement or regulatory agencies, may, by lawful order, obtain disclosure of your personal info rmation. You can find more details about TIC’s privacy policy at www.travelinsurance.ca . If you have any questions regarding our privacy practices, please contact the Privacy Officer at : TIC Travel Insurance Coordinators Ltd 2100 – 250 Yonge Street, Toronto, ON M5B 2L7 Telephone: 416-340-0100 E-Mail: privacy@travelinsurance.ca If you do not agree with our use and disclosure of your information in connection with your application and servicing any polic y that we issue, we will not be able to offer you the insurance product you are interested in, service your insurance or adjudicate your claim. I have read and understood the privacy statement and I consent to the collection, use, retention and disclosure of my personal information or those of my dependants for the purposes stated above. I understand that I may revoke my consent at any time in writing and acknowledge that should I do so, my claim may not be adjudicated. I hereby assign to TIC any benefits obtainable from other sources for losses covered under this policy. I authorize and direct these sources to release payments to TIC and for TIC to release pertinent payments to other parties for the purposes of processing my claim. I certify that the information contained herein is true, complete and accurate and that each of the listed expenses was purchas ed and/or incurred in connection with the medical treatment of the individual(s) named below. I acknowledge that the submission of false or incomplete informati on may result in the delay or denial of this claim. In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning this claim, I ackno wledge and agree that TIC may investigate any information about me, my spouse and/or dependents pertaining to this claim, which may be used and disclosed to any relevant Third Party, and where applicable my plan sponsor, for the purpose of investigating and preventing fraud and/or plan abuse. If I receive payment from TIC in an amount that exceeds the benefit(s) to which I am entitled under the policy (the “overpaymen t amount”), then I acknowledge and agree that: (a) I am indebted to TIC for such overpayment; (b) TIC has the right to recover the overpayment amount through any means available by law; and (c) TIC will offset any benefits payable to me by the overpayment amount until TIC has recovered the overpayment amount in full. I declare my statements above, including all other past and future statements made through personal or telephone interviews rel ating to my claim, to be true, complete, current and accurate. Insured’s Signature: Date: Insured’s Name (please print): Policy #: MM/DD/YYYY
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