Form

Section B: About the sale of the insurance

B.1 when did you take out this payment protection insurance?

can’t remember

B.2 did the payment protection insurance provide single cover (to cover just you)
or joint cover (to cover you and your partner)?

singlejoint

B.3 how was this insurance sold to you?

You might have been sold the insurance at a different time to when you took out your loan or credit.

during a meetingduring a phone conversationyou were given a leaflet to fill inover the internetby postcan’t remember

B.4 did the financial business give you advice or recommend that you take out this
insurance?

yesnocan’t remember

B.5 how did you pay for this insurance?

with a single payment (“premium”) paid up-front as a one-offwith a “premium” paid each monthnot sure

B.6 what’s the current situation with this insurance?

the insurance is still runningthe insurance ended when the loan was paid off(or when the credit card account was closed)the insurance was cancelled (if so, when did this happen?)

B.7 have you ever made a claim on the payment protection insurance you’re
complaining about?

yes*no

* If “yes”, tell us below why you claimed on the policy (for example, you were made unemployed)
and the date of your claim. Also tell us if the insurer turned down your claim.

Please enclose copies of any paperwork you received from the insurer about this claim.

Section C: About the money you borrowed

C.1 what did you buy the payment protection insurance to cover?

a personal loana business loancredit carda mortgagean overdrafta store carda loan secured on your home in addition to your mortgagecatalogue shoppinghire purchasenot sure

what was the account number?

This account number will be different to the insurance policy number on page 1 (at question A.4).

C.2 what was your reason for borrowing the money (or taking out the credit)?

refinancing or consolidating other debts(if so, please complete question C.3 on the next page)buying a carpaying for home improvementspaying for a weddingpaying for a holidaynon-essential spending (for example, buying a new TV)essential everyday spending (for example, rent, household bills or food shopping)business loanother (please tell us more below)

C.3 if you borrowed the money to pay off other debts, please tell us more about those debts?

what were the names of the companies you had those other debts with?

were they credit cards or loans?

how much did you owe?

when did you take them out?

when did you pay them off?

C.4 have you ever missed payments – or gone into arrears – on the loan or credit you listed in question C.1?

yes*no

* If “yes”, please tell us more below.

For example – how many times have you missed payments and by how much – and what’s your current situation?

*Select one*NAI missed payments, but am no longer in arrears.I missed payments and am currently in arrears of:In arrears which are still increasing. Currently:

Section D: About your personal circumstances

D.1 at the time you took out the payment protection insurance, what was your employment status
(and your partner’s – if relevant)?

D.2 if your employment status has changed since you took out the insurance, tell us how.

For example – if you were self-employed, but are now employed.

*Select one*Not changedI am now employedI am now working part timeI am now self-employedI am now an agency/temporary workerI am now retiredI am now unemployed

D.3 what type of work did you do when you took out the payment protection insurance –
and what was the name of your employer?

D.4 how long had you been working there, when you took out the payment protection insurance?

D.5 if you were employed when you took out the insurance, would you have received any pay from
your employer – if you were off work due to sickness or an accident – or if you were made
redundant?

* If “yes”, what pay would you have received from your employer?

less than 3 months3 months or more, but less than 6 months6 months or more, but less than 12 months12 months or moreno pay (or statutory pay)other (please tell us more below)

D.6 if you hadn’t been able to work (because you were ill, in an accident or had been made
redundant), would you have had any other way of making your repayments?

For example – from savings or other insurance policies.

* If “yes”, how would you have made your repayments – if you hadn’t been able to work?

from savings or insurance – worth less than 3 months of your payfrom savings or insurance – worth 3 months or more, but less than 6 months of your payfrom savings or insurance – worth 6 months or more, but less than 12 months of your payfrom savings or insurance – worth 12 months or more of your paynoneby some other means (please tell us more below)

D.7 when you took out this insurance, did you or your partner have any health problems –
or were either of you registered as disabled?

* If “yes”, have you ever been off work because of this condition – and if so, for how long?

Section E: About your complaint

this page is for you to tell us what happened – when you took out the payment protection
insurance

For example, please tell us any details you remember about:

• Where the sale took place – and who you spoke to at the financial business.

• The information you were given before you took out the insurance.

• How the cost, benefits and terms of the insurance were explained to you.

• The questions you asked before taking out the insurance.

• Why you decided to take out the insurance.

Please send us copies of any documents you have from when you took out the payment protection insurance.

finally, tell us why you are now unhappy with the insurance

Section F: Your declaration

You (and your partner, if it’s a joint complaint) need to sign here – even if someone else
is bringing the complaint on your behalf.

If someone is complaining for you (eg a relative or claims manager), your signature here
means you authorise the person named on page 1 to represent you in this complaint.

please tick to confirm you have …

included everything you want to tell us about your complaintsigned the declaration aboveenclosed copies of all relevant documentsnot enclosed any documents with this form

© Financial Ombudsman Service, June 2012.

The Financial Ombudsman Service owns the copyright of this questionnaire. The questionnaire can be freely copied by third
parties involved in bringing or settling financial complaints – as long as no changes are made to the text or graphic design,
and provided that clear reference is made to the Financial Ombudsman Service’s ownership of the copyright.

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