I/We, the undersigned claimant(s) hereby declare that the foregoing statements and particulars of the claim are true and correct and that I/We have not withheld any information relevant to this claim.

I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify Fortitude Insurance Group in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth). I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed “Your Privacy”.

YOUR PRIVACY

The Privacy Act 1988 requires Fortitude Insurance Group to make the following disclosure before collecting personal information about you after 21 December 2001:

• Fortitude Insurance Group collects personal information in order to provide it’s various services which include insurance broking, claims management, risk management consultancy, underwriting management, and reinsurance. 
• If the personal information Fortitude Insurance Group requests from you is not provided, Fortitude Insurance Group or any involved third party may not be able to provide the appropriate services.
• Fortitude Insurance Group discloses personal information to third parties who are involved in the provision of our services. For example, in arranging and managing your insurance needs Fortitude Insurance may provide information (including sensitive information such as health information) to insurers, reinsurers, other insurance intermediaries, it’s advisors such as loss adjusters, lawyers and accountants, and other parties involved in the claims handling process.   By signing this form and continuing to deal with us, you confirm on your behalf and/or on behalf of those you represent consent to Fortitude Insurance and these parties collecting, using and disclosing personal and sensitive information about you.
• Fortitude Insurance Group has a duty to maintain the confidentiality of it’s client’s affairs which includes their personal information. Our duty of confidentiality applies except where disclosure of your personal information is with your consent or required by law.
• Fortitude Insurance Group may make use of your personal information to provide you with information about it’s products and services. 

Further details on the Fortitude Insurance Group Privacy Policy are on our website: www.fortitudeinsurance.com.au

Contact Us

Simply contact the Fortitude Insurance Privacy Officer on the details below if you would like to:

• Access the personal information Fortitude Insurance Group hold about you
• Update or correct the information Fortitude Insurance Group holds about you
• Discuss your privacy concerns
• Be removed from the mailing list to receive information about Fortitude Insurance’ other products and services