Resolved Claims Ltd Tel:

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1 Let s start your PPI claim below. Your Name(s): Home Address: In order to build up a strong case against the lenders we will need as much information as you can possibly provide. Whilst we appreciate that you may not be able to answer every question the more that you can answer will provide us with a good insight as to how your transaction has evolved. If you have any questions that you need answering then please do not hesitate to contact us on / When you first took out the credit agreement how did you apply? A / Via Branch B / Via Mailshot C / Via Telephone D / Via Internet 2 / At the point that you applied for credit were you given any indication of the cost of the insurance either monthly or over the lifetime of the agreement? C / Can t remember 3 / Have you been provided with details from the lender as to what the insurance policy actually covers? 4 / Did the lender recommend that you took out the insurance policy or imply that it was compulsory in order to obtain credit?, I took out the insurance because I had no other insurances in place or any means to repay the agreement should I become ill or unemployed. C / I was not provided with a copy of an agreement to sign where the PPI had not been added so I felt I had no other option 5 / Do you or your immediate family have savings or investments that could be called upon to repay the credit agreement in the short or long term if you were unemployed or were not paid a salary through illness?

2 6 / Do you hold any form of life insurance either via your employment benefits, membership of any trade union or other professional body or that you have taken out yourself? 7 / Have you previously visited the doctor and been diagnosed with any illness that may prevent any possible claim from being accepted such as:- A / Depression, anxiety or any nervous or neurological illness B / Cancer C / Heart disease, liver disease, kidney disease or any major organ impairments D / Aids E / Back disorders F / Multiple sclerosis, ME, or any other degenerative condition G / Any other illness. Please specify:- 8 / About your employment status how would you best describe it. Please tick all statements that apply to you. A / Employed 35 hours per week or more B / Self Employed C / Unemployed D / Retired E / Student F / Seasonal worker G / Part Time work (either employed or self employed) H / Director 9 / How well can you understand what is being given to you to sign or being told to you over the telephone? A / I have hearing problems and I am either deaf or partially deaf. B / I have reading problems and I would not be able to understand what had been written. Please specify reason. C / English is not my first language D / I have problems with my sight and need to wear glasses in order to fully understand what I am signing

3 10 / If you are employed would your employer provide you with any pay in respect of illness? A / No B / 3 months C / 6 months D / 12 months or more 11 / Have you ever claimed or tried to claim on the insurance that the lender sold you? and it paid out in accordance with my needs B / Yes and my claim was refused. Please specify:- C / No 12 / Have you ever previously applied to the lender for a refund of the PPI premiums that you have paid and had you claim declined? A / No B / Yes. If yes then we are unable to accept your claim if the final decision from the lender was received more than 6 months ago 13 / If the loan or the premiums are still being added to your credit agreement would you like these to be stopped moving forward to reduce your monthly payments? C / The loan has been paid in full or I no longer hold such credit card 14 / Are you in arrears with such credit agreement or has it been referred to a debt collection agency because of late or non- payment? I believe that I have been misled in respect of the PPI Product that I purchased and would request that the above information be used as a witness statement for the purpose of pursuing a claim for compensation. Name: Date Of Birth: Signed: Date:

4 Terms & Conditions Mis-Sold PPI Claim I wish to confirm that I have read all the relevant paperwork and document s supplied by Resolved Claims Limited in respect of my claim. I also confirm my comprehension of all verbal advice and information, whether in person or by telephone including but not limited to the following: In the event that my personal circumstances hinder or prevent me from being able to maintain said payments, Resolved Claims Ltd will not accept any liability in respect of the creditor s actions or other agencies pursuing means of obtaining payment. In any case, I indemnify Resolved Claims Ltd of any liability as a result of any non-payments. I understand that I may be sent forms from Resolved Claims Ltd at any time during the claim process as part of the ongoing claim and that I am wholly responsible for the completion and return of the forms to assist in the claim process. In the instance that the claim is successful then I agree to pay Resolved Claims Ltd 25% + VAT of any refund made. In effect this means that you will retain 70% of any refund that you receive after paying our fees. Examples of this are: Refund 1,000 less fees of 250 +VAT of 50 = Net Refund 700. Refund 5,000, less fees of 1,250 + VAT of 250 = Net refund 3,500. Our fees must be paid within 14 days of the date of our invoice. If our invoice for our fees remains outstanding after 30 days, then you will agree to pay us a fee of 30% + VAT of the compensation that you were awarded. I understand that, under The Consumer Contracts (Information, Cancellation and Additional Charges) Regulations 2013, that I have a cooling off period of 14 days within which I may cancel this agreement without incurring a charge. In the event that I cancel this claim after 14 days, then I will agree to compensate Resolved Claims Ltd for any losses incurred, at a rate of 60 per hour. I confirm that any cancellation will be made in writing or by by myself. If you would like Resolved Claims Ltd to provide you with a copy of a standard cancellation form then please contact us by phone or by at I am aware that Resolved Claims Ltd has a complaints handling procedure, and that I have received a copy of this, and this states that if at any time I have reason for complaint or if I am not satisfied for any reason, I will in the first instance illustrate my concerns in writing or by to; The Compliance Manager, Resolved Claims Ltd, Gloucester House, 399 Silbury Boulevard Milton Keynes, MK9 2HL Tel: I understand that in most case the claim will take 2-8 months to complete, but if our solicitors need to issue proceedings against the seller, then this may result in a slight delay in completing my claim. I have read and agreed to the terms and conditions as set out in this document. Signature: Date: I instruct Resolved Claims Ltd to pursue my claim with immediate effect & give my express consent to waive my rights to cancel this instruction under Section 29.1 of The Consumer Contracts (Information, Cancellation and Additional Charges) Regulations (This means that we will act for you straight away as opposed to waiting 14 days for the cooling off period to expire) Signature: Date:

5 Form of Authority Clients Name (1) : Address: Post Code: Telephone Number: Clients Name(2) Address: Post Code: Telephone Number: Name of Lender / Company Lender s / Company s address: Agreement No ( If known): Agreement Start Date: End Date: I/we further authorise and insist that you the firm and /or licensee(s) release to Resolved Claims Ltd, (the company), any information that may be requested from time to time, whether that be in writing, by telephone, , fax or as directed in accordance with the Rights of Data Subjects and Others under the Data Protection Act Please be advised that any wilful failure to comply with this or any other subsequent instruction made by the company acting on my behalf, whom I/we have legally contracted, within the legal requirements as set out by the Compensation Act 1998, The Enterprise Act 2002 and Articles 81 & 82 of the EC Treaty may leave you, the firm or licensee(s), open to legal recourse. If there are other agreements that I have or have had with with yourselves other than the one stated above, then please forward details of these too to Resolved Claims Ltd. Signed (1): Date of birth: Signed (2): Date of birth: Print: Date: Print: Date: Resolved Claims Ltd, Gloucester House, 399 Silbury Boulevard, Milton Keynes, MK9 2AH

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