COMPENSATION CLAIM PACK
Authority & instructions to act on behalf of the Client
Please tick the claim type you wish to make. Allow a separate form for each claim & bank/financial service provider. Bank charges Credit card charges Other _________________________________ Payment Protection Insurance (PPI)
Occupation when loan was taken ___________________________ _______________ ______________
No. of loans/credit cards & approximate amounts: _______________
(please use the reverse of this form if you require extra space)
Loan taken out: In Branch
Over phone
Online
Loan Purpose: _______________________
Did you feel insurance had to be taken to obtain the loan? Yes/No Were the main features/exclusions of the policy explained? Yes/No Were you aware that you could have had the same insurance cover for significantly less elsewhere? Yes/No To: (Name of bank/service provider being claimed against) __________________________________________ Account no./reference no./policy no:
(where unknown please give any sort code, account number and/or any reference number for the company. Alternatively leave blank and a claims advisor will contact you)
Authorisation/Instructions to the company: Claim and Collect have been appointed to act on my/our behalf in pursuing claims against the company stated above. I give my full authority for such claims to be referred to the Financial Ombudsman Service, if this is believed to be in my/our best interest. The service provider has my/our express authority to deal with Claim and Collect as if dealing with me/us in person. Please take this as my/our instruction to you, the company, to send all relevant correspondence to Claim and Collect Ltd, providing them with any information requested. I/we acknowledge that I/we could pursue such claims directly but that I/we have instead opted to engage Claim and Collect Ltd, whose fees will be recoverable from any compensation or settlement awarded to me/us. Redress/Compensation: This letter constitutes a full assignment by me/us to Claim and Collect Ltd of my/our entitlement to compensation or any settlement agreed or awarded to me/us regarding this claim. I/we hereby instruct you to pay any award of redress or compensation to Claim and Collect Ltd. Such monies will be paid promptly to me by Claim and Collect Ltd. Declaration of truth & agreement to terms of engagement: I/we have read and understood Claim and Collect Ltd’s terms of engagement and confirm that I/we have received a copy of these. I/we further declare that all information given in this letter is correct to the best of my/our knowledge. Account holder 1 Title: Surname: Date of Birth: Address: ____________________________________________ Postcode: Tel: Email: Signature: Date: Mob: Tel: Email: Signature: Date: First Name: Account holder 2 Title: Surname: First Name:
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Date of Birth: Address:
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____________________________________________ Postcode: Mob: . .