| Document Date: 2014-09-09 19:41:37
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City Toronto / Calgary / Montreal / / Company Privacy Officer SSQ Insurance Company Inc. / SSQ Insurance Company Inc. / / Facility University Street Suite / University Street / / IndustryTerm sickness insurance / insurance services / insurance intermediary / insurance statistics / insurance / / Position authorized representative / REPRESENTATIVE / REPRESENTATIVE RELATIONSHIP / / ProvinceOrState Alberta / Quebec / Ontario / /
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CONSENT TO COLLECT, USE AND DISCLOSE PERSONAL INFORMATION (ACCIDENT AND SICKNESS CLAIMS) I authorize SSQ Insurance Company Inc. and its authorized representatives to collect, use, and disclose personal information about