Consent

CONSENT FORM FOR THE PROCESSING OF YOUR HEALTH DATA

Dear client,

We need your consent!

Requesting the reimbursement of medical costs after a hospitalisation, mentioning your (temporary) work disability due to an accident at work or in your personal life, or the fact that you were injured during a car accident, these are only a few examples of situations where we process your health data for the servicing of your insurance contract.

In accordance with the General Data Protection Regulation (‘GDPR’) which is applicable as from May 25th 2018 onwards, we need your explicit consent for the processing of this type of data. You may give us your consent by completing the below consent form.

If you do not give us your consent

This may result in Marsh being unable to provide its services any longer. Moreover, this may lead to the insurer being unable to provide its insurance cover any longer.

You also have the right to withdraw your consent at any time.

We respect your privacy and we highly value the confidentiality of your personal data.

Please consult our here (for Belgium) or here for Luxembourg) our Privacy policy where you can read how we process your personal data.

Any further question?

Please find our Q & A.

You may also raise further questions or requests regarding this consent form or regarding our Privacy policy with the local representative of our Data Protection Officer, by emailing to privacy.belgium@marsh.com (for Belgium) or privacy.luxembourg@marsh.com (for Luxembourg) or writing to Marsh sa/nv, Data Protection Officer, Local representative, Avenue Herrmann-Debroux 2 / Herrmann-Debrouxlaan 2, 1160 Brussels (for Belgium) or Marsh sa, Data Protection Officer, Local representative, 16 Rue Robert Stümper, L-2557 Luxembourg (for Luxembourg).

I hereby give my consent to Marsh for the processing of my health data in scope of my insurance contracts.

Last name

First name

Email address

Address (street, street number, postal code, town or city)

Name of your company or organisation of whom you are a member

If you are involved in a claim, please fill in our reference below:

Our ref.

In all other cases, please enter one of the following numbers:

Policy number (Click on + or - to add or remove a policy number)

Client number

Invoice number

If applicable to my insurance contracts, this consent equally applies to the processing of this type of data of the following persons (such as your spouse, partner, parent (s) or children). Click + or – to add or remove a person.

Last name	First name	Date of birth (if minor)	The nature of your relationship

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