Name of Broker

Personal Information and Privacy Notice

Collection of Personal Information

Empire Life will collect sufficient Personal Information to assess this application and, if approved and a contract takes effect as a result, administer the contract. "Personal Information" is any factual or subjective information concerning an identifiable individual. For full details, see the "Use of Personal Information" section below. Depending on the product(s) involved, Personal Information may include, but is not limited to:

contact and demographic information (e.g., name, address, telephone number, email address, date of birth, sex at birth, language preference)
financial information (e.g., banking information,)
medical information (e.g., medical history or that of family members.

Empire Life may also require the person insured(s) to:

undergo medical assessments or provide medical reports to verify pre-existing conditions or assess a claim under the contract, and/or
provide medical documentation or reports from healthcare providers or facilities related to any treatment received while traveling,

as may be required to assess this application or a claim for benefits under the contract, if issued.

If a person insured refuses to provide the required medical information, Empire Life may not be able to assess this application or a claim for benefits under the contract, if issued.<\p> In addition to collecting Personal Information directly from me, Empire Life may also collect it from other persons or organizations, for the purposes set out in the "Use of Personal Information" section below, such as:

its reinsurers,
individual or public or private organization (including any health care professional or practitioner (such as a pharmacist) or clinical lab,
public or private health or social services institution,
other insurance companies or financial institutions, such as a bank, credit union or trust and loan company,
investigation and credit reporting agencies,
the insurance agent and their agency, firm or market intermediaries, and/or
federal and/or provincial authorities or government agencies (e.g. Canada Revenue Agency, regulators, RAMQ (only applicable to Quebec residents)).

Empire Life may also collect Personal Information from third-party service providers engaged to provide services related to, for example:

assessing this application,
contract administration,
underwriting,
claims management,
electronic document signing,
identity management,
cloud services, and/or
risk management, such as fraud management.

In the event of my death, Empire Life may collect Personal Information (e.g. death certificate) from the owner, contingent owner, my beneficiaries, heirs and the personal representative and/or liquidator of my estate for the purposes of assessing a claim under the contract or administering the contract, if issued.

Use of Personal Information

Empire Life, its employees, reinsurers, agents, representatives, and other persons who require Personal Information to perform their duties for Empire Life, and any other person authorized by me, may use Personal Information for the purposes of:

identifying and verifying me,
continually assessing this application, including eligibility for coverage and the nature and amounts of such coverage,
underwriting,
assessing and processing any claim and issuing any benefits or income payments,
conducting audits and investigations,
customer service (e.g., answering my questions, responding to requests and/or concerns),
assessing and managing risk, such as fraud,
meeting its legal and regulatory obligations and requirements,
providing me with information concerning Empire Life products and services (with my consent), and/or
training and educating its staff.

De-identified Data

Empire Life may also use Personal Information to conduct analytic studies or develop artificial intelligence or machine learning. Generally, Empire Life will use de-identified Personal Information for these purposes but if identifiable Personal Information is required, Empire Life will first obtain my consent.

Social Insurance Number (SIN)

Empire Life will use my SIN when it is required for income tax reporting purposes and will not use it for any other purpose without first obtaining consent.

Automated decision-making

When applying for travel insurance, Empire Life uses, and will continue to use, automated decision-making systems to automatically determine whether this application is approved for insurance or declined, whether pre-existing conditions are excluded or covered, and the amount of premiums payable for insurance, if approved.

Disclosure, Location and Retention of Personal Information and Who May Access It

Empire Life may disclose Personal Information to the Advisor(s) (and agency) regarding this application and the contract, if issued, as required, to provide service and advice. Empire Life may also disclose Personal Information to their agents, contractors and reinsurers and their agents and representatives, and any other person authorized by me, for the purpose of assessing this application, administering the contract, if issued, and/or assessing a claim for benefits under the contract. In addition, Empire Life will disclose Personal Information to paramedical service providers and third-party service providers Empire Life engages to provide such services as:

printing and mail services,
legal, accounting and tax services,
auditing and investigations,
payment services,
information technology processing and cloud services,
risk management such as fraud management and identity authentication and contract administration, and/or
actuarial services and underwriting services.

For the current list of third party service providers Empire Life may share Personal Information with, please visit www.empire.ca/third-party-categories.

If Empire Life determines it would be in my best interest to do so (or if required by law), it may also disclose Personal Information gathered about my health (including releasing tests and reports) to my attending physician and to the Chief Medical Officer.

In the event of my death, Empire Life may communicate Personal Information to the beneficiary entitled to proceeds under the contract related to their claim and to the executor or liquidator of your estate to allow them to complete their duties (e.g. documents required for tax reporting purposes) or otherwise as permitted by applicable law.

Access to my Personal Information is restricted to Empire Life employees, agents, representatives, my Advisor (and their agency, firm or market intermediary), reinsurers, third party service providers and other persons who require it to perform their duties for Empire Life, and to persons to whom I have granted access.

Empire Life may store my Personal Information outside my province of residence but within Canada. Empire Life may also disclose my Personal Information to organizations outside my province of residence or outside Canada who process or store my Personal Information as part of their duties for Empire Life. Therefore, my Personal Information may be subject to the laws of other jurisdictions, which may allow disclosure to courts, law enforcement, or other government authorities of those jurisdictions under certain circumstances.

Empire Life will keep my Personal Information for as long as required for the purposes it was collected for and/or as required to meet contractual, legal and/or regulatory obligations and requirements.

My Privacy Rights

I am, or a person authorized by me is, entitled to access my Personal Information and, when applicable, to have my Personal Information corrected. I am also authorized to request information about how my Personal Information is processed and about service providers located outside of Canada that Empire Life has shared my Personal Information with (If the business starts using automated decision-making this is where notice will reside regarding the individual's right to request information about it). I may also withdraw my consent to allow Empire Life to provide me with information about other Empire Life products and services. To do any of these things, or to ask questions or raise a concern about the collection of my Personal Information please write to Empire Life at:

Chief Privacy Officer
The Empire Life Insurance Company
259 King St East, Kingston ON K7L 3A8

To access a copy of Empire Life's most recent privacy policy, please visit our website at www.empire.ca.

Consent

To complete this application, we need your consent to collect, use and disclose Personal Information as described above in the Personal Information and Privacy Notice (referred to as the "Privacy Notice").

Personal Information Authorization

Please respond with "yes" or "no" to the following Consent. Do you:

Understand the Privacy Notice that I have read or that has been read to me by the advisor;
Consent to Empire Life and the other parties referred to in the Privacy Notice collecting, using, maintaining, and disclosing Personal Information for the purposes set out, and as described in the Privacy Notice;
Consent to Empire Life disclosing your personal information to its agents, contractors and reinsurers and their agents for the purpose of completing this application for insurance (referred to as "this application"), administering any contract that takes effect based on this application, and/or assessing a claim for benefits under the contract;
Understand that I can withdraw this consent at any time by notifying Empire Life in writing and acknowledge that if I do so, the broker may be unable to complete this application or, if a contract takes effect based on this application, Empire Life and its agents may be unable to administer the contract and assess a claim for benefits under the contract, and may cancel the contract in its sole discretion, and if this occurs, no benefits will be payable under the contract, and the owner of the contract will be unable to exercise any rights under the contract, and that any action taken in reliance on my consent prior to it being withdrawn will be valid; and

If you disclose Personal information about another individual in this application and, if it is approved, regarding the contract that takes effect, confirm that "Personal Information" also refers to such individual's Personal Information and you are authorized by such individual to disclose their Personal Information and to provide their consent as set out in this Consent.

Medical Questionnaire

Please read out to the applicant:

You MUST answer all questions truthfully and completely. Your answers are relied on by the insurer to determine if your application will be approved and they will become part of the insurance contract, if issued. Nondisclosure or misrepresentations of material information can cause the insurance contract to be voided by the insurer, which means there won't be any coverage, no benefits will be payable and premiums may not be refunded. If you are not the person insured, you must confirm with the person insured that the answers and statements are true and correct as of the Effective Date and, if not, notify the broker immediately.

For each question, answer "Yes" for any condition if the proposed person insured has had signs or symptoms of the condition, or been investigated for, received consultation or Treatment for, had a change in medication or Treatment for, been Hospitalized for, or been diagnosed with the condition. You can answer "no" if a condition has been specifically ruled out and no further follow-up action has been or needs to be taken.

Do not provide any information about genetic tests in this application or on any other forms submitted to us.

Notes to Broker:

If the Application Date and Effective Date are different, remind the applicant to contact you immediately if a disclosed condition changes or the person insured develops a new condition or has a change in medications prior to the Effective Date.

Check whether the stated period of stability is based on the Effective Date or the Application Date.

Person Insured/Policyowner

The person insured must be the policyowner, unless they are a minor (under age 18 in Quebec or age 16 in all other provinces and territories). For minor persons insured, the policyowner must be the minor's parent or legal guardian, who must reside at the same address as the person insured.

Beneficiary

Notes to Broker

Advise the policyowner on the rules that apply:

Naming beneficiaries: Identify each beneficiary by their legal first and last name, date of birth, and relationship to the person insured. If naming >1 beneficiary, each will have an equal % unless you state otherwise. Total shares must equal 100%.
Minors: Benefits will not be paid directly to a minor beneficiary. Outside Quebec, please name a trustee who can receive insurance proceeds on behalf of the minor beneficiary. In Quebec, benefits will be paid to the beneficiary's tutor(s) or legal guardian(s) unless you have appointed an administrator or established a formal trust.
For all provinces except Quebec: All beneficiary designations will be presumed revocable unless you state otherwise.
For Quebec: Married or civil union spouses are deemed irrevocable unless you state otherwise.
Irrevocable Beneficiary Designations: If you designate a beneficiary irrevocably:
1. you cannot change or revoke the beneficiary;
2. you may not exercise certain rights to control the contract, including to cancel it, without the beneficiary's written consent;
3. in Nova Scotia, you must also complete an Irrevocable Beneficiary Designation Supplement (INS-3207); and
4. if the irrevocable beneficiary is a minor, you cannot change or revoke the beneficiary or control the contract unless, where permitted by law, a court order is obtained. A minor irrevocable beneficiary cannot provide consent.

For details, please refer to the "Beneficiary for Accidental Death Benefit" section of the policy contract or click on the sample Beneficiary Designation form here.