:: Antwerp Insurance Agency ::
::Antwerp Insurance Agency ::
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Antwerp Insurance Agency, Inc
PO Box 1088
312 S. Main St.
Antwerp, OH 45813
Ph. (419)258-5511
Fax (419)258-2822
Antwerp Insurance Agency, Inc.
Privacy Policy Notice

We do not sell your information to anyone.

Title V of the Gramm- Leach-Bliley Act (GLBA) and the laws of the State(s) of Ohio
and Indiana, 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 applicable State laws, we are
providing you with this document, which notifies you of the privacy policies and
practices of Antwerp Insurance Agency, referred to in the rest of this document as
"AIA".

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:
Information we receive from you on applications other forms. Information about your
transactions with us, our affiliates or others. Information we receive from a
consumer reporting agency. Information we receive from medical records or
medical professionals.

B. Persons From Whom Information is Collected
We may collect nonpublic personal information from individuals other than those
proposed for coverage.

C. Information From Credit Reports or Investigative Consumer Reports
We may obtain information about you from credit reports or other investigative
consumer reports prepared by third parties at our request. You have the right to
request to be interviewed in connection with the preparation of such a report. Upon
request, you are entitled to receive a copy of the report. The information obtained
from the report prepared by the third party may be retained by the third party and
disclosed to other persons.

2. Information we may disclose to third parties:
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:

To a third party if the disclosure will enable that party to perform a business,
professional or insurance related function for us;

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;

To a lending institution in connection with liens against property that you insure with
us;

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;

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, facilitate
the payment of a claim, or conduct an audit that would enable us to verify treatment;

To an 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;

To a group policyholder for the purpose of reporting claims experience or
conducting an audit of our operations or services;

In addition to those circumstances listed above, and unless you tell us not to, we
may disclose certain information about you to third parties whose only use of the
information will be for purposes of marketing a product or service. Under no
circumstances will we disclose for marketing purposes any medical information;
information relating to a claim for benefit or, a civil or criminal proceeding involving
you; or personal information relating to your character, personal habits, mode of
living or general reputation.

3. Third parties with whom we share certain information protected by the Fair Credit
Reporting Act, unless you tell us not to:
A: Information we obtain from your insurance application, such as your income or
your marital status; Information we obtain from a consumer report, such your credit
score or credit history; Information we obtain from a person regarding its
employment, credit, or other relationship with you, such as your employment history.

B. Third party companies who may receive this information are:
Financial service providers, such as: insurance companies, investment brokerage
companies.

C. If you prefer that we not share this information with third party companies, you
may direct us not to share this information by doing the following:

Call us at (419)258-5511 or
E-mail us at tim.derck@antwerpinsuranceagency.com or
Complete our opt out form

4. 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 of 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 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: Tim Derck, Antwerp Insurance
Agency,,PO Box 1088, Antwerp, OH 45813. 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: Tim Derck, Antwerp Insurance
Agency,,PO Box 1088, Antwerp, OH 45813. The request should include your name,
address, social security number, telephone number, the specific information in
dispute, and the identity of 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 an
opportunity to challenge.

5. 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.

6. 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.

7. Reservation of the right to disclose information in unforeseen circumstances:
In connection with the potential sale or transfer of its interests, AIA and its affiliates
reserves the right to sell or transfer your information (including but not limited to
your address, name, 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 or service; (2) agrees to be
AIA'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.

THE REMAINDER OF THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW TO OBTAIN ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

1. Statement of Our Duties
We are required by the Health Insurance Portability and Accountability Act of 1996 to
maintain the privacy of your personal health information and to provide you with this
notice of our privacy practices and legal duties. We are required to abide by the
terms of this notice. We reserve the right to change the terms of this notice and to
make any new provisions effective to all of the personal health information that we
maintain about you. If we revise this notice, we will provide you with a revised notice
in the following manner via US Mail or through your employer.

2. Statement of Your Rights
You have a right to know how we may use or disclose your personal health
information. This notice informs you of those uses and disclosures. There are
certain uses and disclosures of your personal health information that we are
permitted or required to make by law without your permission. For all other uses
and disclosures, we first must obtain your permission. In addition, you have the
following rights:

(a) The right to request that we place additional restrictions on our uses and
disclosures of your personal health information (beyond what the law requires), but
we are not obligated to agree to any such additional restrictions. (b) The right to
access, inspect and copy the protected information pertaining to you that we
maintain in our files about you, and the right to have us correct or amend any
information that we create in error. (c) The right to receive an accounting of the
disclosures of your personal health information that we make for purposes other
than activities related to your treatment, or our payment functions or other health
care operations. (d) The right to request that you receive communications of
personal health information in a confidential manner.

3. Permissible Uses and Disclosures of Protected Health Information
(a) Payment Functions. We may use or disclose your health information without
your permission to carry out activities relating to reimbursing you for the provision of
health care, obtaining premiums, determining coverage, and providing benefits
under the policy of insurance that you are purchasing. For example, payment
functions may include (but are not limited to) reviewing health care services with
respect to medical necessity, coverage under the policy, appropriateness of care,
or justification of charges.

(b) Health Care Operations. We also may use or disclose your protected health
information without your permission to carry out certain insurance-related activities.
These activities include using your protected information for underwriting, premium
rating, or other activities relating to the creation, renewal or replacement of another
contract of health insurance, and ceding, securing, or placing a contract for
reinsurance of risk relating to claims for health care.

(c) Uses Permitted/Required By Law. We also may use or disclose your protected
health information without your written permission for purposes permitted or
required by law.

(d) Authorized Uses. All other uses or disclosures of your protected health
information will be made only with your written permission, and any permission that
you give us may be revoked by you at any time.

4. Complaints About Misuse of Health Information
You may complain either directly to us or to the Secretary of Health and Human
Services if you believe that your rights with respect to our protection of your health
information have been violated. To file a complaint with us, you may file a complaint
with us in writing. The request should include your name, address, social security
number, and telephone number. You must include specific information regarding
the violation including the names of the individuals and/or companies involved as
well as the date(s) of the event(s). You will not be retaliated against in any way for
filing a complaint.

5. Contact Person for Filing Complaint or Obtaining Further Information
Tim Derck, Antwerp Insurance Agency, PO Box 1088, Antwerp, OH 45813
.
Privacy Notice