1 Title. 2 Full Name (Please include names of all policy holders) 3 Address. 4 Phone. 5 Mobile number. 6

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2 1 Title 2 Full Name (Please include names of all policy holders) 3 Address 4 Phone 5 Mobile number 6 7 Date(s) of birth 1st Applicant 2nd Applicant 8 Have you currently complained to the company involved? If so please give details 9 Are you currently in IVA, debt management or bankruptcy? 10 Please list any medical conditions at the time you took out the PPI policy Sort Code Are you on means tested benefits? Yes No

3 This page only to be completed for PPI (Payment Protection Insurance) policies Name of company that sold you the PPI policy: Policy number: Loan/PPI start date: Loan amount: Monthly PPI premiums: If repaid loan or cancelled PPI please give date: If you have made a claim under your insurance cover, was it successful? Please Tick as Appropriate I was or was shortly to become self-employed when I took out the policy. I was retired or very close to retirement age when I took out the policy. I was not employed (including student) when I took the payment protection policy. I was a Public Services employee when I took out the policy. I was told the payment protection policy was compulsory. I was not aware that payment protection was optional. I had other protection policies in place when I took out this credit card / loan. My pre-existing medical conditions were not discussed at the point of sale. I was not made aware that any pre-existing medical conditions would not be covered by the policy. I was told I would get a better interest rate if I took the policy out with the credit card / loan. I was not made aware of the cost of the premiums for this policy. I was not aware that the payment protection insurance cost would be added to the loan and I would pay interest on the cost. I was not made aware that I had taken out a payment protection policy when I took out the credit card/loan. I was not made aware that I could purchase alternative payment protection policy with another provider when I took out the credit card/loan. I did not need the insurance as I could have repaid the loan/outstanding balance using my savings. 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 was not made aware that the policy did not cover the life of the loan. We have a joint loan but the PPI only covers one of us. I tried to cancel the PPI before March 2007 and was advised this was not possible. I paid off my loan early and did not receive a refund of interest added for my PPI cover. I/we have completed this questionnaire to the best of our knowledge. 1st Policy Holder Signature 2nd Policy Holder Signature Date: Date:

4 Client Name Client Address Post code Company(ies) Loan/Account/Credit Card Number(s) 6 I/we have read, understood and agree to be bound by the Terms & Conditions as provided in our claims pack and available on the company website:

5 Definition of Terms "The Company" means Claims Thru Us Limited trading as Canary Claims. "You", "I", "We" means the person or persons entering into a Contract for the provision of the Services of the Company. "Contract" means the signed authority & agreement between You and the Company relating to the supply of the services incorporating these terms of business. "Services" means all or any of the services as specified in the Contract. 1 What Canary Claims will do for you: The Company will assess your case and, if appropriate, pursue a claim for redress on your behalf in respect of financial services mis-selling and/or unfair penalty charges. The Company offer this service on a no win no fee basis. The Company will as your agent with general authority to process and administer your claim to seek redress. The Company will evaluate the redress offered to you and let you know if the Company consider the sum put forward is fair. At our discretion, the Company will pursue your claim through the Financial Ombudsman Service, the FSCS or the law courts. 2 What Canary Claims will not do: The payment of redress will go direct to you (the client) and not to the company. The Company will not accept an offer of redress on your behalf without your agreement. The Company will not give you financial advice. 3 What the Company expect from you: To provide all relevant information so that the Company can pursue your claim. To provide the Company with authority to receive all information and enter into all negotiations on your behalf. 4 Our fees: Our fee is 20% + VAT (web only offer) of the total redress amount received. The Company does not charge a fee if no redress is awarded. There is no fee payable in advance. The banks may request a 10 fee before they release historic statements of account. The Client agrees to pay this fee if required. A minimum charge of 50 is applied to all successful claims. 5 Cancelling this agreement: The Company can cancel this agreement at any time. In such an event there will be no fee payable by you. You have the right to terminate the contract by giving written notice to the Company within 14 days of signing this Contract. Notice should be made in writing to the Company and sent by recorded delivery. In the event that the Client terminates the Contract after 14 days, the Company reserves the right to make a cancellation charge reflective of the work carried out up to the point of cancellation of our Service. If notice of termination is received after the complaint has been upheld then the Company reserves the right to charge the full fee of 20% + VAT of the forthcoming redress. 6 Data protection: Canary Claims will process information in accordance with the Data Protection Act The Company may disclose your information to other companies as the need may arise during your claim. Canary Claims will not sell or disclose your personal details for marketing purposes. 7 Client declaration: I/we confirm that I/we have read and understood the above terms and conditions and by signing below confirm acceptance. I/we authorise Canary Claims to act on my/our behalf. I/we confirm that I/we have read and understood the Data Protection statement. This agreement is a binding contract and by signing it you are accepting its terms Signed Print Date Signed Print Date This agreement relates to the following PPI policies and/or credit card and/or bank accounts: Loan Account Credit Card Numbers

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