The CILEx Compensation Fund Claims Application Form

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1 The CILEx Compensation Fund Claims Application Form Please complete this form to make a claim for a loss you have incurred. When you have filled in the form, please send it to us at: The CILEx Compensation Fund Kempston Manor Kempston Bedford MK42 7AB DX Kempston 2 Phone: Fax:

2 INTRODUCTION Please complete this form to make a claim from The CILEx Compensation Fund, where you have incurred a loss caused by reason of the actions of an entity regulated by CILEx Regulation. This form asks for details about you, the entity that dealt with your matter and the loss you have incurred. It is important that you attempt to answer all of the questions as this information will assist The CILEx Compensation Fund in assessing your claim. In completing this form you should refer to the CILEx Compensation Fund Guidance document. This guidance is intended to help and provide you with information on how your claim will be assessed and what you should expect. If, at any time, you have any queries please contact The CILEx Compensation Fund. The contact details can be found on the front of this application form. Page 2 of 12

3 Part 1 Your Information Please provide the following information about you. If you are completing this form on behalf of someone else please provide the details of the person who incurred the loss. Mr Mrs Ms Miss Other Surname or family name (Please give details) All other names in full OR Organisation name (where an organisation has incurred the loss): Address: Postcode: Daytime contact number(s): address: If you have already contacted us, please quote our reference number: Are you aware of anyone else, or any organisation, who may have a claim in the same transaction or who needs to know about this claim? Yes No If Yes, please give details. Page 3 of 12

4 Part 2 Your Claim This section asks for details about your claim 1. Provide the name of the entity you are making this claim against: 2. Entity s address and postcode: 3. What is the amount of the grant you are applying for: 4. Please give the date (or approximate date) on which you first became aware that you may have incurred a loss: 5. Please give details of any other people who may have an interest in this application. Please say what that interest is. 6. Are you able to claim any part of the loss from another source, for example, insurance? Yes No If Yes, please give details. 7. Have you made any attempts to recover your loss through any other route? Yes No If Yes, explain what action you have already taken. 8. Have you instructed a new legal representative to act for you in the transaction? Yes No If yes, please give their name and address below. Page 4 of 12

5 9. If we do not make a payment, will you or any other person suffer hardship as a result? Yes No If Yes, please give details. We may need further information or evidence to support your claim. We will let you know if this is the case. Page 5 of 12

6 Part 3 Your Case This section asks you to explain the transaction that led to the loss. 10. What type of work was the entity doing for you? Please provide as much information as possible along with any available supporting evidence. Please include the following: a) how the entity came to have the money you are applying for; b) when the entity received the money; c) what work the entity was doing for you; d) how far the entity had got with the work; e) when you first became aware of the loss; and f) how you became aware of the loss. Page 6 of 12

7 Please complete on a separate sheet if necessary Part 4 Declaration I confirm that I was a client of this entity and I want to claim for a loss that I have incurred. I understand that if I am not entitled to some or all of the money I receive, I will return it to CILEx within 30 days of being notified of such a matter. I confirm that I have suffered financial loss as a result of the entity s dishonesty or failure to pay me money that they received and I am suffering or likely to suffer hardship. If I receive money from The CILEx Compensation Fund, I acknowledge that CILEx will be entitled to any rights I may have against the entity to the extent of any payment made to me. CILEx may take legal proceedings in my name on the basis that CILEX will protect me against any legal costs. I transfer to CILEX and The CILEx Compensation Fund any rights I may have to recover the loss from the legal practice. I give CILEx and The CILEx Compensation Fund permission to gather any information they need from other people and to give other people information about my claim. The information I have given in this form is true to the best of my knowledge and belief. I acknowledge that I must tell The CILEx Compensation Fund about any other information (for example, any money I recover or if I am made bankrupt) which may be relevant to this claim. If I am signing this form as the representative of another person, I confirm that they have authorised me to sign it. Your name: Your signature:. Date: The signature of the person claiming with you (in the case of joint claims only) Your name Your signature: Date:.... Page 7 of 12

8 ADDITIONAL INFORMATION Please complete this section if you are completing this application on behalf of the applicant and your relationship to the applicant. Mr Mrs Ms Miss Other Surname or family name (Please give details) All other names in full OR Organisation name (if you are a lawyer or professional acting on behalf of the applicant): Address: Postcode: Daytime contact number(s): address: Provide details of your relationship to the applicant: Page 8 of 12

9 Diversity Monitoring Form Gender What is your gender? Male Female Age From the list of age bands below, please indicate the category that includes your current age in years: Disability The Equality Act 2010 generally defines a disabled person as someone who has a mental or physical impairment that has a substantial and long-term adverse effect on the person s ability to carry out normal day-to-day activities. (a) Do you consider yourself to have a disability according to the definition in the Equality Act? Yes No Page 9 of 12

10 If yes, please state the type of disability that applies to you. You may experience more than one type of impairment, in which case you may tick more than one. Physical impairment Hearing impairment Visual impairment Learning disability or difficulty Mental Health condition Long-standing illness or health condition Other (please specify) Ethnic group What is your ethnic group? Asian/Asian British Bangladeshi Chinese Indian Pakistani Any other Asian background (please specify) Black/African/Caribbean/Black British African Caribbean Page 10 of 12

11 Any other Black/Caribbean/Black British (please specify) Mixed/multiple ethnic groups White and Asian White and Black African White and Black Caribbean White and Chinese Any other Mixed/multiple ethnic background (please specify) White British/English/Welsh/Northern Irish/ Scottish Irish Gypsy or Irish Traveller Any other White background (please specify) Other ethnic group Arab Any other ethnic group (please specify) Page 11 of 12

12 Religion What is your religion? No religion Buddhist Christian (all denominations) Hindu Jewish Muslim Sikh Any other religion (please specify) Sexual Orientation What is your sexual orientation? Bisexual Gay man Gay woman/lesbian Heterosexual/straight Other Page 12 of 12

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