Welcome to Successful Claims Web Service
Thank you for Downloading you‟re Application Forms. There is a little bit of writing to do but when it
finished Send them off and we do the rest.
Please find enclosed your customer pack. You are now a step closer to establishing your claim(s).
Successful Claims provide a professional claims management service, reviewing your loan, higher
purchase and credit card agreements to determine whether payment protection insurance (PPI) has been
mis-sold to you.
It is important that all documents are signed and returned to enable us to start your claim.
FINAL CHECKLIST
Have you Read Completed and Signed:
Terms and Conditions □ Don‟t forget to keep a copy for yourself. Print Another.
Letter of Engagement □
Letter of Authority □
Questionnaire □
Statement of Events □
Section F - Declaration for Financial Ombudsman □
Copies of all your policy documents □
(We will send back any original documents.)
Please ensure that you enclose any policy documents you have and any previous correspondence you
have had with the company concerned over this policy.
A recent credit card or loan statement can be helpful if you don‟t have the original paperwork.
Once received we will process your claim immediately and you should hear from us within 4 - 6 weeks,
however, please be patient. Your policy seller may take a number of weeks to process your claim owing
to the increasing number of claims being made against Financial Institutions.
Please return your completed pack to:
Successful Claims 12 Malvern Close, St Julians, Newport, Gwent, South Wales. NP19 7NS
If you have any further questions or need help in completing the pack please contact us on 01633 262105 or
Email and we will get back to you.
12 MALVERN CLOSE · ST JULIANS · NEWPORT · GWENT · SOUTH WALES · NP19 7NS
Telephone 01633 262105 Email successfulclaims@btinternet.com
Successful Claims Jordanna Jakeway, T/A (trading as) Successful Claims
Regulated by the Ministry of Justice in Respect of Regulated Claims Management Activities · Authorisation Number CRM 25174
Data Protection Number Z2416539 · VAT Registration Number 108 9968 65
Frequently Asked Questions
Q. WHAT IS PPI ?
A. Also known as Accident, Sickness and Unemployment cover (ASU), LIfe & Accident, Sickness and Unemployment cover (Life
& ASU), Mortgage Payment Protection Insurance (MPPI), Personal Loan Protection (PLP) or Credit Card Repayment Protection
(CCRP), these policies are often sold alongside your credit card, loan or mortgage, or are „stand alone‟ policies that are not
linked directly to a specific product or credit arrangement.
These policies are intended to pay your monthly credit card or loan payments should you become unemployed or ill and find
yourself unable to pay the monthly amount.
WHY CAN I CLAIM?
Many companies sell these policies without informing the clients they are optional, without fully assessing the client‟s
employment status or medical history and in many cases this leads to people being sold policies they can never claim on.
If it was mis-sold to you then you can make a claim to get back the proportion of your monthly loan or credit-card payments that
represented the PPI payments, plus interest. There are many reasons why PPI may have been
mis-sold to you in the first place but the main reasons behind making a claim are described below.
When you take out a PPI policy there are certain circumstances under which you cannot receive its benefit. if you were
unemployed, a student, retired or self-employed when you took out the policy you may have not been able to benefit from the
policy under any circumstances a strong indication that mis-selling took place is you may have been told that you wouldn‟t get
the loan without PPI? If so, you may well have been mis-sold the policy. PPI is an optional extra and cannot be included as a
requirement when taking out a loan or credit card. Is the policy suitable for your needs and the loan it covers?
Were you even aware that you had taken out PPI when you took on the loan? Some credit card application forms, particularly for
store cards, contained a box that you had to tick if you didn‟t want PPI cover. The Financial Services Authority has since
clamped down on this and new credit card applications require the customer to opt-in if they want PPI.
A lot of policies are charged as a single lump sum on top of the loan which results in you paying interest on the policy too. If you
were not made aware of this, it was probably mis-sold. Some policies last only five years for loans that run far longer (sometimes
even 25 years). This would indicate it is unsuitable for that loan and you probably have a claim.
Finally - if you settled the loan early you might have received an unfairly low rebate of the PPI policy premium you paid as an up-
front sum. We can get a fairer refund for you.
WHAT WILL I HAVE TO DO?
Just fill in and sign the enclosed forms and return them to us in the envelope provided and we‟ll do the rest. We may need you to
sign additional forms as your case progresses, usually to accept an offer from your lender or forms required by the Financial
Ombudsman Service.
DO YOU NEED MY CREDIT-CARD STATEMENTS OR LOAN AGREEMENTS?
No we don‟t, but it can speed things up. We can write to your lender and use the Data Protection Act to force them to inform us
of all the PPI charges they‟ve charged you. Companies are usually pretty slow in responding to these requests so if you do still
have some of the original documents then please send us copies as it may mean you get your money back sooner.
CAN I DO THIS MYSELF?
The simple answer to that is, yes you can but when you use our service all the work is done for you.
HOW MUCH CAN I CLAIM?
You can claim back mis-sold PPI costs plus interest for the last six years. If you paid off your loan early and received little or no
refund, we can make a claim for a larger refund, as companies are only allowed to charge reasonable administration charges.
WILL I HAVE TO GO TO COURT?
It‟s extremely unlikely. In exceptional cases we might need you to attend court in order to explain what your lender‟s salesperson
said but we‟re always there with you and you can always decide to abandon your claim if it gets to that stage.
HOW LONG DOES IT TAKE?
This very much depends on how long your lender takes to respond to us. Eight to twelve weeks is typical but if we need to
involve the Financial Ombudsman or courts it can take an additional six to nine months. We keep you updated on progress at all
times.
HOW MUCH DOES IT COST?
For a successful claim, we charge you 25% of the money reclaimed + VAT. For example, if we recover £1000 then our charges
are £300 incl. VAT which leaves you with £700.00 - If we don’t win your case, there is absolutely nothing to pay us.
12 MALVERN CLOSE · ST JULIANS · NEWPORT · GWENT · SOUTH WALES · NP19 7NS
Telephone 01633 262105 Email successfulclaims@btinternet.com
Successful Claims Jordanna Jakeway, T/A (trading as) Successful Claims
Regulated by the Ministry of Justice in Respect of Regulated Claims Management Activities · Authorisation Number CRM 25174
Data Protection Number Z2416539 · VAT Registration Number 108 9968 65
SSign and Return with Pack
TERMS and CONDITIONS for the appointment of Successful Claims to act on the Client’s behalf in all aspects of the administration
and negotiation of the claim.
1. Definitions
1.1 “Claim(s)” means the Client‟s claim or claims against the Company relating to the mis-selling of a payment protection insurance policy or policies.
1.2 “Client” means the policyholder/account holder(s), whose details are set out in the Letter of Authority and who have appointed Successful Claims to provide the Services.
1.3 “Company” means the Financial Institution and or persons to whom the Letter of Authority is addressed being the Insurance Company, Bank, Building Society, Credit Card
Company or Financial Advisor or any other entity which sold the policy or gave the advice to the Client. (including for the avoidance of doubt any employee, director, agents,
representatives and associates of said entities or any other entity and/or any of their predecessors).
1.4 “Compensation” means any sums paid or awarded as calculated at the time of the award that would not have been paid if the Claim had not been made.
1.5 “Successful Claims” means, Successful Claims Sole Trader and third party claims handler. (12 Malvern Close, St Julians, Newport, Gwent, South Wales, NP19 7NS).
1.6 “Fee” means the fee of 25% + VAT of the Compensation, payable to Successful Claims for the Services carried out by it. For example, if we recover £1,000 compensation, our fee
would be £300.00 (inclusive of VAT at 20% the current rate) and you would receive £700.00
1.7 “Letter of Authority” means the letter included in the claim pack to be sent to the Company from the Client.
1.8 “Services” means the services provided by Successful Claims including assessing the viability of, preparing, submitting and negotiating your Claim.
1 .9 „„Terms” means these Terms and Conditions,
2. Conduct of Engagement
2.1 By signing and returning the Letter of Authority, the Client hereby agrees to be bound by the Terms and appoints Successful Claims to provide the Services for such period as to
allow Successful Claims to assess, and if reasonably possible, to complete the Claim.
3. The Client will:
3.1 by completing and signing the Letter of Authority give Successful Claims
his/her/their consent and full authority to deal with the Company on the
Client‟s behalf and to obtain relevant information from whatever source on
a continuing basis.
3.2 deal promptly with every reasonable request by Successful Claims for authority, information and documents and further instructions that Successful Claims may from time to time
require. Failure to do so will give Successful Claims the right to terminate this Agreement forthwith and the Client will reimburse Successful Claims its reasonable costs incurred in
pursuing the Claim to the date of termination.
3.3 promptly inform Successful Claims of any relevant matters affecting the Claim.
3.4 hereby assign his/her/their entitlement to any Compensation to Successful Claims. The Client hereby agrees to the Company remitting the Compensation to Successful Claims and
for Successful Claims to retain the Fee before paying the balance of the Compensation to the Client. Notwithstanding such agreement, should the Compensation be paid directly to the
Client, or negated from his/her/their mortgage or loan, Successful Claims will invoice the Client for the Fee which will become immediately due and payable by the Client to
Successful Claims. If this fee is not paid in full within 28 days of the dated invoice it shall be deemed a termination of the Agreement and will fall under clause 3.6.
3.5 give Successful Claims the right to deal exclusively with the Claim, unless otherwise agreed in writing by the Client and Successful Claims.
3.6 Termination: (a) Successful Claims may terminate this agreement should the amount recoverable be deemed to be insufficient to progress. (b) I/We may terminate our instructions
by providing written notice to Successful Claims within 14 days of the date of this document. (It is recommended that you send any notice of cancellation by recorded delivery post).
Termination after this period will be at the discretion of Successful Claims and only then in exceptional circumstances, I/we will be liable for those costs which are equal to the sum
payable in my/our case should my/our claim have been settled in full. Should the value of my/our claim be unknown then I/we may be liable for the reasonable costs incurred by
Successful Claims at the rate of £35 per hour, or part thereof.
3.7 for the avoidance of doubt not be liable for any charge in respect of the Claim if the Claim is pursued and the Company pays no Compensation.
4. Successful Claims will:
4.1 rely on the information and documents provided by the Client to Successful Claims as being true, accurate, and complete. Successful Claims will not audit, test or check such
information or documents except where it is under a legal obligation to do so.
4.2 use its reasonable endeavours to obtain the maximum Compensation for the Claims which are pursued.
4.3 accept no liability for a Claim that is not successful or for the amount of compensation paid to the Client.
4.4 promptly notify the Client if the Claim is not to be pursued. It is at Successful Claims‟s sole discretion to decide whether or not to proceed with the Claim at any time during the
claims process but Successful Claims must act reasonably in taking any such decision.
4.5 promptly notify the Client of the outcome of the Claim.
4.6 as soon as is reasonably practicable following the settlement of a Claim and the payment of Compensation by the Company to Successful Claims, pay the Client the balance of the
Compensation, after deducting the Fee. and
4.7 preserve confidentiality including the Client‟s personal information (even when this Agreement has terminated and the Client is no longer a Client), save as expressly or implicitly
authorised to the contrary including where disclosure is made at the Client‟s request or with the Client‟s consent in relation to pursuing the Claim or where otherwise required by law.
5. Disclaimer
5.1 Successful Claims accepts no liability for any loss suffered by the
Client by entering into this Agreement and specifically in the event that no
Compensation is paid to the Client by the Company. Any claim by way of
consequential damage arising out of any act or omission or commission by
Successful Claims is specifically excluded.
5.2 You are aware that you could complain directly to the Company at no cost, with the ability to take matters further with the Financial Ombudsman Service yet still wish to pursue
your complaint via Successful Claims.
5.3 Please note you have 14 days (which starts from the date you signed the authority) to cancel your authority instructing us to act on your behalf.
5.4 Full details of Successful Claims‟s internal complaints handling procedures are available upon request.
5.5 Successful Claims is regulated by the Ministry of Justice in respect of regulated claims management activities.
Authorisation number is CRM 25174
6 Governing Law
6.1 This Agreement shall be subject to the laws of England and Wales.
I/we the client(s) have read and understand the terms and conditions of this agreement and by signing below confirm our acceptance.
Signature (1) ………………………………………………… Date ....../……./….. Signature (2) …………………………………… Date ....../……./…..
12 MALVERN CLOSE · ST JULIANS · NEWPORT · GWENT · SOUTH WALES · NP19 7NS
Telephone 01633 262105 Email successfulclaims@btinternet.com
Successful Claims Jordanna Jakeway, T/A (trading as) Successful Claims
Regulated by the Ministry of Justice in Respect of Regulated Claims Management Activities · Authorisation Number CRM 25174
Data Protection Number Z2416539 · VAT Registration Number 108 9968 65
Letter of Engagement
Account Holder 1 Account Holder 2
First Name: Initial(s): First Name: Initial(s):
............................................................................................................................................. .............................................................................................................................................
Surname: Surname:
……………………………………………………………………………………………………… ………………………………………………………………………………………………………
Address: Address:
……………………………………………………………………………………………………… ………………………………………………………………………………………………………
……………………………………………………………………………………………………… ………………………………………………………………………………………………………
............................................................................................................................................. .............................................................................................................................................
POST CODE: POST CODE:
............................................................................................................................................. .............................................................................................................................................
TELEPHONE: TELEPHONE:
……………………………………………………………………………………………………… ………………………………………………………………………………………………………
Email: Email:
……………………………………………………………………………………………………… ………………………………………………………………………………………………………
DATE OF BIRTH: -- -- DATE OF BIRTH: -- --
……………………………………………………………………………………………………… ………………………………………………………………………………………………………
Your address when the Loan / Credit Agreement was taken out. ( if different ):
…………………………………………………………………………………………………………………………………………………………………………………………………………………..
...............................................................................................................................................................................................................................................................................................
………………………………………………………………………………………………………………………………………………………POST CODE…………………………………………..
This document confirms the agreement between you (“the Client” ) and Successful Claims (“the Company”).
I/We hereby appoint the Company to act on my/our behalf as my/our sole representative of any claim for Compensation in respect of my
prospective claim(s) for mis-sold PPI (Payment Protection Insurance) on my/our loan(s), mortgage(s) or credit card(s). I/we shall provide
all information required by the Company. I/we shall not enter into any agreements with the lender seller without first consulting the
Company I/we understand that Solicitors may work with the Company and may commence proceedings against my lender for
Compensation.
The Company makes no representation or warranty to the Client that Compensation will be obtained or is in any way guaranteed. The
Company reserves the right, at any time, and at their sole discretion, not to pursue a claim for Compensation and will notify the Client in
writing in such cases.
I/We understand that we will be charged a fee of 25% + VAT if we win your claim. For example, on a successful claim of £1,000 the fee
would be £300.00 including 20% VAT. Leaving the Client £700.00
I hereby give my permission for a photocopied version of the document to be taken as an original authority.
I/We agree, by signing below, to be bound by the Terms and Conditions.
I/We agree, by signing below, to be bound by this Agreement, and wish the Company to act on my/our behalf.
I/We also confirm by signing this document that the Company instructed on my/our behalf has my/our formal and irrevocable authority to
deduct the fee detailed above and that this authority remains in full force and effect for the purpose of any Third Parties and that the
Company, may direct any Third Parties on our behalf to pay the fee set out.
PLEASE NOTE THAT ALL ACCOUNT OR POLICY HOLDERS MUST SIGN THIS FORM
Account Holder 1 ( Signature ) Account Holder 2 ( Signature )
……………………………………………………………………………………… …………………………………………………………………………..
Date Date
…………/……………/…………… …………/……………/……………
12 MALVERN CLOSE · ST JULIANS · NEWPORT · GWENT · SOUTH WALES · NP19 7NS
Telephone 01633 262105 Email successfulclaims@btinternet.com
Successful Claims Jordanna Jakeway, T/A (trading as) Successful Claims
Regulated by the Ministry of Justice in Respect of Regulated Claims Management Activities · Authorisation Number CRM 25174
Data Protection Number Z2416539 · VAT Registration Number 108 9968 65
Letter of Authority Page 1
Account Holder 1 Account Holder 2
First Name: Initial(s): First Name: Initial(s):
............................................................................................................................................. .............................................................................................................................................
Surname: Surname:
……………………………………………………………………………………………………… ………………………………………………………………………………………………………
Address: Address:
……………………………………………………………………………………………………… ………………………………………………………………………………………………………
……………………………………………………………………………………………………… ………………………………………………………………………………………………………
............................................................................................................................................. .............................................................................................................................................
POST CODE: POST CODE:
............................................................................................................................................. .............................................................................................................................................
DATE OF BIRTH: -- -- DATE OF BIRTH: -- --
……………………………………………………………………………………………………… ………………………………………………………………………………………………………
Your address when the Loan / Credit Agreement was taken out. ( if different ):
…………………………………………………………………………………………………………………………………………………………………………………………………………………..
...............................................................................................................................................................................................................................................................................................
………………………………………………………………………………………………………………………………………………………POST CODE…………………………………………..
NAME OF LENDER - BANK - CREDIT CARD PROVIDER
…………………………………………………………………………………………………………………………………………………………………………………………………………………..
ADDRESS
...............................................................................................................................................................................................................................................................................................
………………………………………………………………………………………………………………………………………………………POST CODE…………………………………………..
Account or Agreement Number
…………………………………………………………………………………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………………………………………………………………..
As provided for under Rule DISP 2.7.2 R of the FSA Handbook which states that “A complaint may be brought on behalf of an eligible
complainant or a deceased person who would have been an eligible complainant by a person authorised by the eligible complainant or
authorised by law”. I/we the undersigned authorise Successful Claims to act on my/our behalf as agents in pursuing my/our complaint(s) in
connection with mis-sold PPI (Payment Protection Insurance) that have been applied to my/our account over the past six years.
I/We confirm that we have a lawful contract with Successful Claims and have expressly consented that all communication and payments
from you must be made direct to Successful Claims. This instruction relates to all products or claims with relation to the above named
client.
I/We hereby advise that wilful failure to follow my/our express instructions with regard to dealing with Successful Claims whom I/we have
contracted with may render the offending party liable to legal recourse for procuring/ inducing a breach of contract; restraint of trade;
breaches of the Competition Act 1988, the Enterprise Act 2002 and Articles 81 & 82 of the EC Treaty
Please take this letter as authority requiring you to deal directly with Successful Claims and to provide any information that Successful
Claims requests as necessary to pursue my/our complaint(s) fully. This authority will endure until further notice.
All future correspondence should be forwarded to Successful Claims. Compensation should be paid in the form of a cheque and made out
to Successful Claims.
Please treat this as my/our authority for you to deal directly with my representative and to provide any information that they request as
necessary to pursue my/our complaint(s) fully. This authority will endure until further notice.
I/We agree, by signing below, to be bound by the Terms and Conditions.
PLEASE NOTE THAT ALL ACCOUNT OR POLICY HOLDERS MUST SIGN THIS FORM
Account Holder 1 ( Signature ) Account Holder 2 ( Signature )
……………………………………………………………………………………… …………………………………………………………………………..
Date Date
…………/……………/…………… …………/……………/……………
12 MALVERN CLOSE · ST JULIANS · NEWPORT · GWENT · SOUTH WALES · NP19 7NS
Telephone 01633 262105 Email successfulclaims@btinternet.com
Successful Claims Jordanna Jakeway, T/A (trading as) Successful Claims
Regulated by the Ministry of Justice in Respect of Regulated Claims Management Activities · Authorisation Number CRM 25174
Data Protection Number Z2416539 · VAT Registration Number 108 9968 65
Application to make a Claim - QUESTIONNAIRE Page 2
Name :
Address :
Post Code :
Telephone : Mobile
Email : Date of Birth / / Sometimes required by lender
Credit Card
What was your PPI Policy Sold with? Loan – Mortgage Car Finance
Store Card
Who is the Policy with? (Example - Capital One, Barclays, Lloyds )
When was the Policy Sold? (Just the year needed)
Where was the Policy Sold? (Telephone. Internet. At the bank. A store. Home. Broker. )
Policy – Loan Number? ( or Credit Card Number )
Are you in arrears with this loan / credit card? Details of arrears.
Are you currently bankrupt, in an IVA or debt management Programme? YES NO
Is the Loan or Credit Card associated with this PPI policy fully paid off now?
YES NO
THIS WILL NOT AFFECT A CLAIM.
Loan Amount or Average credit card balance?
Any Original Documents will
Do you have the original paperwork (Please send to us with claim) YES NO
be returned to you.
Cost Of PPI ?
If PPI cancelled or paid please give date?
If you made a claim under your PPI cover was it successful? YES NO
Occupation at time of Loan/PPI : Occupation Now :
PLEASE TICK AS APPROPRIATE
I was or was shortly to become self-employed when I took
I was not made aware of the cost of the premiums for this policy.
out the policy.
I was retired or very close to retirement age when I took out I was not aware that the payment protection insurance cost would be added to
the policy. the loan and I would pay interest on the cost.
I was not employed (including student) when I took the I was not made aware that I had taken out a payment protection policy when I
payment protection policy. took out the credit card/loan.
I was not made aware that could purchase alternative payment protection
I was a Public Services employee when I took out the policy.
policy with another provider when I took out the credit card/loan.
I was told the payment protection policy was compulsory. I did not need the insurance as I could have repaid the loan/outstanding
balance using my savings.
I was not aware that payment protection was optional. I did not receive any notification on why the policy recommended was
suitable to my needs. (Only applies if PPI taken after 14 January 2005)
I had other protection policies in place when I took out this
I was not made aware that the policy did not cover the life of the loan.
credit card / loan
My pre-existing medical conditions were not discussed at
We have a joint loan but the PPI only covers one of us.
the point of sale.
I was not made aware that any pre-existing medical I tried to cancel the PPI before March 2007 and was advised this was not
conditions would not be covered by the policy. possible.
I was told I would get a better interest rate if I took the I paid off my loan early and did not receive a refund of interest added for my
policy out with the credit card / loan. PPI cover.
I /We have completed this questionnaire to the best of my/our knowledge. I understand it is my duty to provide correct information.
Policy Holder 1 (Signature) ………………………………………………………………………….. Date ………/………/……….
Policy Holder 2 (Signature) ………………………………………………………………………….. Date ………/………/……….
12 MALVERN CLOSE · ST JULIANS · NEWPORT · GWENT · SOUTH WALES · NP19 7NS
Telephone 01633 262105 Email successfulclaims@btinternet.com
Successful Claims Jordanna Jakeway, T/A (trading as) Successful Claims
Regulated by the Ministry of Justice in Respect of Regulated Claims Management Activities · Authorisation Number CRM 25174
Data Protection Number Z2416539 · VAT Registration Number 108 9968 65
Statement of Events Page 3
For the benefit of your claim we require a statement regarding the circumstances under which your
disputed policy was sold to you. Please take time to complete and return this statement along with your
claims forms.
If you can recall specific details of the circumstances under which your policy was sold, what it covered,
conversations with the sales person or your concerns at the point of sale, please include them within the
statement - Any details you can provide will help to support your claim further.
If you are claiming on several policies, please complete a declaration for each policy.
Name of PPI Policy Provider:
……………………………………………………………………………………………………………………………………………
Policy Number ……………………………….……………………………………………………………………………………
I believe I was mis-sold this payment protection policy because:
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
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……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
Declaration: I/We confirm we have completed the statement to the best of my/our knowledge, and
confirm it is a true account of the events in the sale of my/our PPI policy.
Signature (1): Date:
……………………………………………………………………………………………………………………………………………………………………..
Signature (2): Date:
………………………………………………………………………………………………………………………................................................................
12 MALVERN CLOSE · ST JULIANS · NEWPORT · GWENT · SOUTH WALES · NP19 7NS
Telephone 01633 262105 Email successfulclaims@btinternet.com
Successful Claims Jordanna Jakeway, T/A (trading as) Successful Claims
Regulated by the Ministry of Justice in Respect of Regulated Claims Management Activities · Authorisation Number CRM 25174
Data Protection Number Z2416539 · VAT Registration Number 108 9968 65
section F: your declaration
Please read and sign this declaration
I confirm that I want to make a formal complaint about the sale of the
payment protection insurance described in this questionnaire.
I confirm that all the information I have given in this questionnaire
is true and accurate to the best of my knowledge.
sign here
You need to sign, even if someone else is complaining on your behalf.
If someone is complaining for you, your signature below means you
authorise the person named on page 1 to represent you in this complaint.
……………………………………………………………………………………………………. ………………………………………………
signature date
……………………………………………………………………………………………………. ………………………………………………
signature date
© Financial Ombudsman Service, March 2010
The Financial Ombudsman Service owns the copyright to this questionnaire. The questionnaire can be freely
copied by third parties involved in bringing or setting financial companies – 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.
payment protection insurance: consumer questionnaire page 7 of 8
12 MALVERN CLOSE · ST JULIANS · NEWPORT · GWENT · SOUTH WALES · NP19 7NS
Telephone 01633 262105 v
Email successfulclaims@btinternet.com
Successful Claims Jordanna Jakeway, T/A (trading as) Successful Claims
Regulated by the Ministry of Justice in Respect of Regulated Claims Management Activities · Authorisation Number CRM 25174
Data Protection Number Z2416539 · VAT Registration Number 108 9968 65