Steers Insurance Personal Information Disclosure Request Form. Please Note: A $25.00 application fee is required for request. Request for: [ ] Access to Own Personal Information [ ] Correction to Own Personal Information Name of Brokerage request made to: Steers Insurance Limited 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 to 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, is 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: By Mail: Steers Insurance Limited PO Box 1776 St. John's, NL AIC 5P9 Attention: Privacy Compliance Officer On the web: www.steersinsurance.com By phone: (709) 722-1532 Ask for: Privacy Compliance Officer By facsimile: (709) 722-1532 Attention: Privacy Compliance Officer