CUSTOMER NOTICE FOR THE TREATMENT OF PERSONAL DATA
Dear Sir / Madame,
Siscos, whom you gave authorization to follow your claims until the payment of reimbursements and
benefits, would like to give you some information.
The Leg. Dec. 30 June 2003 n. 196 (Personal Data Protection Code) provides for the protection of personal
data, and establishes that data of the interested person must be kept and utilized in transparency, with a view
to defend the rights of the person involved.
This is to inform you that Siscos is in possession of some personal data about you. In compliance with art. 13
of Italian Leg. Dec. 30 June 2003 n° 196, Siscos will register, treat and keep your personal data as follows:
in its electronic data bases;
to carry out all its duties with the insurance companies and brokers, until the final reimbursement of
claims and benefits for the insured person and his family members.
Rights enshrined in Art. 7 – The data subject has the right to obtain confirmation on the existence of
his/her personal data; to know how they were acquired; to ask for data cancellation; to change into
anonymous ones or to seal off those personal data treated violating law; the right to update, to rectify or to
complete his/her data; and the right to oppose him/herself their treatment.
Person in charge of the processing/data controller – Siscos, via Giovanni Devoti, 16 – 00167 Rome, is in
charge of the data treatment. On this behalf, Siscos reserves itself the right to treat and process
your personal data, should it be necessary to:
perform the duties prescribed by law or UE rules and regulations;
carry out all duty necessary to assist the insured persons.
SISCOS
SISCOS – Servizi per la Cooperazione internazionale
Via Giovanni Devoti, 16 – 00167 Roma – C.F. 97562510582
Tel. +39 06 66031039 – Fax +39 06 66032774 – e-mail: [email protected]
NGO ASSOCIATION
ADHESION FORM TO THE TEMPORARY
INSURANCE IN CASE OF DEATH – Policy INA n° 9.017.951 (former 35012)
INSURED: Surname …………..………….………………………. Name ....……………………………...
Born on …………... in …………………………………………… Country………………………..…….
Sex
M
F
Passport n. …………………………………………..
(please attach copy of the passport)
Address: ..………………………………..……………………. Town …...…………………………………
Zip code ………………………. Country ……………….……………..………………………..……..…...
Beneficiary in case of death (specify only if different from heir-at-law):…………………….…………………..…………
With effect from h 24.00 of ……………………… Duration n° quarters (select): 1
TICK THE OPTION REQUIRED:
a.
Guarantees:
€
50.000,00
Tick only if the insured works in a de-mining unit
2
b.
150.000,00
3
4
c.
250.000,00
The Insured declares to know – with reference to dispositions written in Art.1919 of Italian Civil Code – that this application
form serves as a base for his admission to the Collective Life Policy stipulated between the Policy Holder and INA S.p.A.
DECLARATION OF THE INSURED CONCERNING HIS HEALTH
Knowing that the information I give will constitute the basis on which the INA S.p.A. will give his assent to the
insurance coverage, I declare what follows:
A) the date I fill up this form, I am in good health, and in the last five years I did not take exams which showed
abnormal situations, and I was not hospitalized nor submitted to surgical operations (*);
B) being unable to declare what in the previous A) sentence, I declare having suffered or still suffering of the
following diseases or handicap or having undergone the following surgical operations (*):
Date
Type
Outcome
…………………..…..…..
……………….………
……………….….………….……
………………………..
………………………..
……..………………
…………………….
…………………………….….
………………………………..
I also declare, seen the articles 1892 and 1893 of Italian Civil Code, to assume all responsibility for information provided, and I
confirm they are truthful. I acquit all doctors, Public and Private Institutes of any sanitary information, and I authorize them to
give information and certifications without any exclusion.
Seen the notice for treatment of personal data, under Art. 13 of Italian D.Lgs. 196/2003, I give my consent to the
treatment of my personal data, and sensitive information, enshrined in Art.4/d) of Italian D.Lgs. 196/2003.
Date ………………………….
Signature of the Insured……………..……………………….
(*) Surgery intervention for Appendectomy, Tonsillectomy, Herniectomy, Saphenous vein cutdown, Varicose vein,
Hemorrhoidectomy, Meniscectomy, Limb fracture, Nasal septum deviation, Cholecystectomy since more than 3 months and
Gastric resection of ulcer since more than one year, are exluded.
The information contained in this form is confidential. It may also be legally privileged. It is intended only for the stated addressee(s) If you are
not an addressee, you must not disclose, copy, circulate or in any way use the information contained in this mail. Such unauthorised use may be
unlawful.
INA – ASSITALIA – Life Policy – Collective n. 90.17.951
INFORMATIVA E CONSENSO AL TRATTAMENTO DEI DATI PERSONALI COMUNI E SENSIBILI
CUSTOMER NOTICE AND CONSENT FOR THE TREATMENT OF PERSONAL DATA
(Italian D.Lgs. 196/2003)
In ossequio alla normativa vigente, La informiamo che la nostra Società e l’Agenzia Generale indicata in polizza – autonomi
Titolari del Trattamento – tratteranno i Suoi dati personali con le modalità e procedure – effettuate anche con l’ausilio di
strumenti elettronici – strettamente necessarie per fornirLe i servizi assicurativi richiesti.
In accordance with the law, we inform You that our Society and the General Agency mentioned in the Policy – that are in
charge of the data treatment – will treat your personal data following direction and procedures – eventually using also
electronic data bases - necessary to provide You the insurance services requested.
Tali dati possono essere conosciuti dai rispettivi collaboratori in qualità di Responsabili o di Incaricati dei trattamenti
suddetti; per taluni servizi possono essere utilizzate Società del Gruppo ed altre Società di fiducia, che svolgono per nostro
conto compiti di natura tecnica, organizzativa e operativa in qualità di Responsabili o di Titolari autonomi di trattamenti. I
Suoi dati non sono oggetto di diffusione.
These data may be known by their partners who are Responsible of the treatment of the data; some services may require
the employment of other Societies of the Group and other trusted Societies, which carry out services of technical,
organizational and operative nature, as Responsible of the treatment of the data. Your data will not be released.
Ai sensi dell’art.7 del D.Lgs 196/2003 Lei ha diritto di conoscere, in ogni momento, quali sono i Suoi dati presso di noi e
come vengono utilizzati; ha inoltre il diritto di farli aggiornare, rettificare, integrare, cancellare, chiederne il blocco ed opporsi
al loro trattamento.
According to Art.7 of Italian Law, D.Lgs 196/2003 You have the right to know, in every time, which data we process and the
way they are used; you also have the right to ask that your data be updated, corrected, completed, cancelled. You may also
ask they are blocked or to oppose their treatment.
Lei potrà esercitare tali diritti e richiedere ogni informazione in merito ai soggetti o alle categorie di soggetti cui vengono
comunicati i dati o che possono venirne a conoscenza in qualità di Responsabili o Incaricati preposti ai trattamenti sopra
indicati, rivolgendosi:
all’INA ASSITALIA S.p.A. – Servizio Privacy di Gruppo c/o Assicurazioni Generali, Piazza Venezia, n.11, 00187
Roma, tel. 06/4722.4865 fax 041/2593999 – Responsabile designato per il riscontro all’interessato in caso di esercizio dei
diritti di cui all’art. 7 del D.Lgs 196/2003. Il sito www.inaassitalia.it riporta ulteriori notizie in merito alle politiche di privacy
della nostra Società, tra cui l’elenco aggiornato dei Responsabili ed il testo di informativa aggiornato.
All’Agenzia Generale indicata in polizza.
You can ask any information to:
INA ASSITALIA S.p.A. – Servizio Privacy di Gruppo c/o Assicurazioni Generali, Piazza Venezia, n.11, 00187
Roma, Italy. Tel. +39 06/4722.4865 fax +39 041/2593999 – that is responsible to answer customers requests, when
they exercise the rights enshrined in Art. 7 of Italian Law D.Lgs 196/2003. Furthermore, the website
www.inaassitalia.it reports further information on Privacy Policy of our Society; it reports also the complete list of
people in charge of the data treatment and the precise text of customer notice.
- The General Agency mentioned in the Policy.
Sulla base di quanto sopra, apponendo la Sua firma in calce, Lei può esprimere il consenso al trattamento dei dati, anche
sensibili, effettuato dalla Società e dall’Agenzia Generale, alla loro comunicazione ai soggetti sopra indicati e al trattamento
da parte di questi ultimi.
Read what witten above, signing the form, You can give Your consent to the treatment of Your data by the Society and the
General Agency mentioned in the Policy, and give our consent to the trasmission of Your data to others, as indicated above,
and to their treatment of Your data.
COGNOME E NOME / FULL NAME _______________________________________________________
N. DI PASSAPORTO / PASSPORT NUMBER _______________________________________________
FIRMA DELL’ASSICURANDO / SIGNATURE OF THE INSURED ___________________________________
DATA / DATE ______________________