Privacy Web Form

Pour remplir cette demande de divulgation en français, veuillez cliquer sur le bouton en haut à droite de votre écran.

Please complete this form to submit your Third-party Information Disclosure Request.

This request for disclosure is made in accordance with Provincial and Federal privacy legislations and regulations.

Important:

Echelon Insurance will verify the information submitted with this request. Hover over the questions to view tips that will assist in completing the form.

I am a member of

Required

Requesting Organization Name

Full Name of Requestor

Role/Position

Office Phone Number

Cell Phone Number

Office Mailing Address

Select Province or Territory

This request is for the disclosure of

Required

Please select all that apply.

Provide the following information to assist in the search of records

Please submit a separate form for each individual.

Name of Individual

Policy/Claim Number

Date of Birth

Last Known Address

VIN

Vehicle Make/Model

Date of Loss

License Plate Number

Please provide more information about the disclosure request.

In your explanation, identify and describe each of the following, if applicable: the specific agreement; the investigation; the proceeding; the crime; the relevant laws; the particulars of the breach; the particulars of the fraud; reasons why the knowledge or consent of the individual would compromise the investigation or the ability to prevent, detect, or suppress fraud; any relevant evidence that supports your position.

Consent

Required

Additional Information

To confirm your submission, please print your full name below

If you have any documentation in support of your request, please attach it using the button below. Up to 10 files may be selected. Please note that you will only be able to attach supporting documents once you have filled in the CAPTCHA code above.