Pedersen, Dowie, Clabby & McCausland Insurance Inc.

(PDCM Insurance)

Independence Insurance Services

LaPorte City Insurance

PRIVACY NOTICE

This notice is in effect as of July 01, 2001

THIS NOTICE DESCRIBES HOW MEDICAL OR FINANCIAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

1. Statement of Our Duties

We are required by law to maintain the privacy of your non-public personal health or financial 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 non-public personal health or financial information that we maintain about you. If we revise this notice, we will provide you with a revised notice as required by applicable law.

2. Statement of Your Rights

You have a right to know how we may use or disclose your personal health or financial information. This notice informs you of those uses and disclosures. There are certain uses and disclosures of your personal health or financial 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:

• The right to request that we place additional restrictions on our uses and disclosures of your personal health or financial information. However, we are not obligated to agree to impose any such additional restrictions.
• 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. Requests to access or amend your health or financial information should be sent to the contact person and address provided in item #8.
• The right to receive an accounting of the disclosures of your personal health or financial information that we make for purposes other than activities related to your treatment, our payment functions or other health care or insurance operations.
• The right to request that you receive communications of personal health or financial information in a confidential manner.
• In the event this privacy notice is provided electronically you have the right to obtain a paper copy of this notice from us upon request.

3. Information We Collect About You

We collect the following categories of information about you from the following sources:

• Information that we obtain directly from you, in conversations or on applications or other forms that you fill out.
• Information that we obtain as a result of our transactions with you.
• Information that we obtain from your medical records or from medical professionals.
• Information that we obtain from other entities, such as health care providers or other insurance companies, in order to service your policy or carry out other insurance related needs.

4. Permissible Uses and Disclosures of Protected Information

To Carry Out Treatment or Coverage Functions. We may use or disclose your health or financial information without your permission for health care or property & casualty providers to provide you with treatment or coverage.

To Carry Out Payment Functions. We may use or disclose your health or financial 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. Such functions may include reviewing health care services with respect to medical necessity, coverage under the policy, appropriateness of care, or justification of charges.

To Carry Out Certain Operations Relating To Your Benefit Plan. We also may use or disclose your protected health or financial information without your permission to carry out certain limited activities relating to your health or property & casualty insurance benefits, including reviewing the competence or qualifications of health care professionals and conducting quality assessment activities.

In Situations Permitted Or Required By Law. We also may use or disclose your protected health or financial information without your written permission for other purposes permitted or required by law.

As authorized by and to the extent necessary to comply with workers compensation or other no-fault laws.

To a health oversight agency for activities including audits or civil, criminal or administrative proceedings.

To a public health authority for purposes of public health activities (such as to the Food and Drug Administration to report consumer product defects).

To a law enforcement official for law enforcement purposes or in response to a court order or in the course of any judicial or administrative proceeding.

To organ procurement organizations, or to other entities for approved research purposes.

To a government authority, including a social service or protective service agency, authorized to receive report of abuse, neglect or domestic violence.

For Any Purposes To Which You Have Not Objected. In certain limited circumstances, we may use or disclose your protected health or financial information after we have given you an opportunity to object and you have not objected. For example, if you do not object, we may use limited information about you to maintain an office directory, to notify family members or any other person identified by you regarding issues directly related to such person?s involvement with your care or payment of that care, or in emergency circumstances.

For Purposes For Which We Have Obtained Your Written Permission. All other uses or disclosures of your protected health or financial information will be made only with your written permission, and any permission that you give us may be revoked by you at any time.

5. Complaints About Misuse of Health or Financial 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 or financial information have been violated. To file a complaint with us, you may submit a written statement including as many details such as names and dates as possible to Pedersen, Dowie, Clabby & McCausland Insurance, Attn. Human Resource Director, P.O. Box 2597, Waterloo, Iowa 50704. You will not be retaliated against in any way for filing a complaint.

6. Our Practices Regarding Confidentiality and Security.

We restrict access to nonpublic personal health and financial 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.

7. 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.

8. Contact Person For Filing Complaint or Obtaining Further Information.

Pedersen, Dowie, Clabby & McCausland Insurance Inc.

Attn: Human Resource Director

3927 University Avenue

Waterloo, Iowa 50701

Mailing:

P.O. Box 2597

Waterloo, Iowa 50704

Phone and Fax

(319) 234-8888 or 1-800-373-2821

Fax: (319) 234-7702

E-Mail

Human Resource Director

hrdirector@pdcm.com