Personal Information Update Form IU(AC)

SECTION 1 – MEMBER INFORMATION ON RECORD

SECTION 2 – CHANGE OF PERSONAL INFORMATION

Note: Select the applicable box and provide only the information that has been changed. Certain changes may require supporting documents.

Part A – Change of Member Information

Contact Information


Mailing Address

Legal Name

Proof : Name Change Certificate / Driver’s License / Marriage Certificate / Other Supporting Document

Marital Status


Social Insurance Number

Please attach: SIN Confirmation Letter / SIN Card / Other Supporting Documents

Date of Birth

Proof : Driver’s License / Birth Certificate / Other Supporting Documents

Gender

Proof : Birth Certificate / Driver’s License / Other Supporting Documents

Part B – Change of Spouse or Common-law Information

Spouse Name


Spouse Date of Birth


Part C – Change of Employment Information (To be completed by employer only)

Hire Date


Plan Entry Date


SECTION 3 – AUTHORIZATION, DECLARATION AND CONSENT

Collection, Use and Disclosure of Personal Information
The administrator of your group pension plan is Coughlin & Associates Ltd. (“Coughlin”). Personal information (including the SIN) is collected and used to administer members’ pension benefits. The information collected may be disclosed to other organization, or person including the Trustees, Financial Institutions, Insurers and Government Agencies for the administration of pension plan, tax reporting identification, and use of the foregoing information for statistical purposes.

Retention of Personal Information
We retain personal information for only as long as it is needed to accomplish the purpose for which it was collected, or as needed for authorized, legitimate. or legal purposes. We recognize and respect every individual’s right to privacy. When personal information is provided to us, we establish a confidential file that is kept in our facilities or in the facilities of an organization that we authorize. We limit access to information in your file to our personnel or other persons we authorize, who require the information to perform their duties with respect to these plans, to persons to whom you have granted access, and to persons authorized by law.

Access to Personal Information
Members and Participating Employers have a right to request access to and correction of any personal data. Requests can be made in writing to the Privacy Officer at 1403 Kenaston Blvd., Winnipeg, MB R3P 2T5.

I understand and agree to the terms of the Personal Information Collection Statement as set out in this form.

I declare that to the best of my knowledge and belief, the information given and statements made in this form and / or its attachment(s), if any, are true, correct and complete.


Member’s Name

Date

Employer Number

Employer Name

Authorized Person’s Name

Date