PERSONAL INFORMATION REQUEST/COMPLAINT FORM

Client Name: _________________________________________________________________________

Address:
 




 
Telephone Number: Home ___________________________ Office ___________________________

Fax
(if any): ___________________________________________________________

Email address
(if any): __________________________________________________

Insurer
(if known):_______________________

Policy #
(if known):_______________________

Check the applicable box, if you wish to file a request or complaint regarding your 
personal information which is being or has been held or processed by JLT Canada.
(Please briefly state the nature of your request or complaint):


 
 
 
 
 
 
 
 
 
 
Signature of Client
 
Date Signed
FOR OFFICE USE ONLY:
Date received: ___________________________ By (print name):_________________________
Date acknowledged: ______________________ By (print name):_________________________
Date of response: ________________________  By (print name): ________________________