Siskiyou
Insurance Services, Inc.
Privacy Policy Notice
(as of { July 1, 2001} )
PURPOSE OF THIS NOTICE Title V of the Gramm-Leach-Bliley
Act (GLBA) and the laws of the State of California generally prohibit
us from sharing nonpublic personal information about you with a third
party unless we provide you with this notice of our privacy policies
and practices describing the type of information that we collect about
you and the categories of persons or entities to whom that information
may be disclosed. In compliance with the GLBA and California law, we
are providing you with this document, which notifies you of the privacy
policies and practices of Siskiyou Insurance Services, Inc.
OUR PRIVACY POLICIES AND PRACTICES
1. Information we collect:
A. Categories of Information Collected and Sources From
Which We Collect It. We collect nonpublic personal information about
you from the following sources:
1) Information that you provide us on applications and other forms.
2) Information about your transactions with us from the insurance companies
we contact to underwrite your insurance.
3) Information we receive from the Department of Motor Vehicles or other
consumer reporting agencies.
4) Information contained in medical records or from medical professionals
that is related to insurance claims. Unless it is specifically stated
otherwise in an amended Privacy Policy Notice, no additional information
will be collected about you.
B. Persons From Whom Information is Collected. We may
collect nonpublic personal information from individuals other than those
proposed for coverage.
2. Information we may disclose to third parties:
We do not disclose information about you to third parties whose only
use of the information is to market a product or service. However, in
the course of our general business practices, we may disclose the information
that we collect (as described above) about you or others without your
permission to the following types of institutions for the reasons described
below:
A. To a third party if the disclosure will enable that party to perform
a business, professional or insurance function for us.
B. To an insurance institution, agent, or credit reporting agency in
order to detect or prevent criminal activity, fraud or misrepresentation
in connection with an insurance transaction.
C. To an insurance institution, agent, or credit reporting agency for
either this agency or the entity to whom we disclose the information
to perform a function in connection with an insurance transaction involving
you.
D. To a medical care institution or medical professional in order to
verify coverage or benefits, inform you of a medical problem of which
you may not be aware, or conduct an audit that would enable us to verify
treatment.
E. To the California Department of Insurance or other insurance regulatory
authority, law enforcement, or other governmental authority in order
to protect our interests in preventing or prosecuting fraud, or if we
believe that you have conducted illegal activities.
F. To a group policyholder for the purpose of reporting claims experience
or conducting an audit of our operations or services.
3. Your right to access and amend your personal information: You have
the right to request access to the personal information that we record
about you. Your right includes the right to know the source of the information
and the identity o the persons, institutions or types of institutions
to whom we have disclosed such information within 2 years prior to your
request. Your right includes the right to view such information and
copy it in person, or request that a copy of it be sent to you by mail
(for which we may charge you a reasonable fee to cover our costs). Your
right also includes the right to request corrections, amendments or
deletions of any information that is in our possession. The procedures
that you must follow to request access to or an amendment of your information
are as follows: To obtain access to your information: You should submit
a request in writing to Robert D. Reed, Siskiyou Insurance Services,
Inc., P.O. Box 492871 Redding, Ca 96049-2871. The request should include
your name, address, social security number, telephone number, and the
recorded information to which you would like access. The request should
state whether you would like access in person or a copy of the information
sent to you by mail. Upon receipt of your request, we will contact you
within 30 business days to arrange providing you with access in person
or the copies that you have requested. To correct, amend, or delete
any of your information: You should submit a request in writing to Siskiyou
Insurance Services, Inc. (address above). The request should include
your name, address, social security number, telephone number, the specific
information in dispute, and the identity of the document or record that
contains the disputed information. Upon receipt of your request, we
will contact you within 30 business days to notify you either that we
have made the correction, amendment or deletion, or that we refuse to
do so and the reasons for the refusal, which you will have the opportunity
to challenge.
4. Our practices regarding information confidentiality and security:
We restrict access to nonpublic personal information about you to those
employees who need to know that information in order to provide products
or services to you. We maintain physical, electronic, and procedural
safeguards that comply with federal regulations to guard your nonpublic
personal information.
5. Our policy regarding dispute resolution: Any controversy or claim
arising out of or relating to our privacy policy, or the breach thereof,
shall be settled by arbitration in accordance with the rules of the
American Arbitration Association, and judgment upon the award rendered
by the arbitrator(s) may be entered in any court having jurisdiction
thereof.
6. Reservation of the right to disclose information in unforeseen circumstances:
In connection with the potential sale or transfer of its interests,
Siskiyou Insurance Services Inc., and its affiliates (if any), reserve
the right to sell or transfer your information (including but not limited
to your name, address, age, sex, zip code, state and country of residency,
and other information that you provide through other communications)
to a third party entity that (1) concentrates its business in a similar
practice, product or service; (2) agrees to be Siskiyou Insurance Services
Inc.’s successor in interest with regard to the maintenance and protection
of the information collected; and (3) agrees to the obligations of this
privacy statement.
7. Customer acknowledgement and signature: By signing my name below,
I am indicating that I have read the privacy policy of Siskiyou Insurance
Services, Inc. }, and that I understand its terms. No promises or representations
have been made to me to induce me to sign this form.
________________________________________________________________________ Customer Name, Signature & Date
