REVIEWING YOUR PAYMENT PROTECTION INSURANCE. To help us review the sale of your Payment Protection Insurance (PPI) please complete all of the sections below, to the best of your knowledge. We will aim to get back to you within 8 weeks of receiving your complaint. SECTION A - YOUR PERSONAL INFORMATION Please enter your details below. Unique Ref Num: POST YOUR FORM Please return your completed form to: Capital One P.O. Box 5281 ttingham NG2 3HX A1 Main Account Holder Current Address Previous Addresses (including the address at the time the account was opened). Contact Tel. We may need to contact you in order to process your complaint quicker. Date of Birth D D M M Y Y Y Y Email Address A2 If someone is complaining on your behalf (eg a relative or claims manager) please give us their details Their Name Relationship to you Address for writing to them (including postcode) Their Tel. Their Ref. Their Email A3 16 digit credit card number: Page 1 of 7
SECTION B - PPI B1 Date PPI was sold to you SECTION C - PERSONAL CIRCUMSTANCES C1 At the time you took out PPI (refer to sale date in Section B) what was your employment status? Employed Temporary / Agency worker If this applies to you, we may ask you for further evidence. Director - but not of own company Student in full-time or part-time education Student and working 16 or more hours per week Working fewer than 16 hours Working in Armed/Police forces t known Other please specify Self employed Director of own company If this applies to you, you must provide evidence such as letter from tax office (HMRC*) showing that you were paying CLASS 2 or CLASS 4 NATIONAL INSURANCE. This must be for the same tax year you took out the insurance. t working Retired If this applies to you, you must provide evidence such as letter from tax office (HMRC*) showing that you were not paying any NATIONAL INSURANCE contributions. This must be for the same tax year you took out the insurance. * HMRC are able to provide information for you if you no longer have it available. Please contact them on 0845 302 1479 between 08:00 and 17:00 Monday to Friday to request your National Insurance information and 0845 300 0627 between 08:00 and 20:00 Monday to Friday and 08:00 and 16:00 on Saturdays to request your income information. C2 What was your occupation at time of sale? C3 Name of employer C4 Annual income at time of sale Page 2 of 7
C5 At the time of sale, how long had you been working for this employer? M M Y Y C6 If you were employed when you took out PPI, would you have received any pay from your employer if you were off work due to sickness or an accident or if you were made redundant? Can t remember t relevant (as you weren t employed) C7 If yes, what pay would you have received from your employer? pay (or statutory pay) Less than 3 months 3 months or more, but less than 6 months 6 months or more, but less than 12 months 12 months or more Other (please explain) If this applies to you, you must provide evidence such as a letter from your employer or your contract of employment which confirms your sick pay allowance or redundancy allowance at the time of sale. C8 If you were unable to work (because you were ill, in an accident or made redundant), how would you have made your Capital One credit card payments after paying all your other essential bills? other means to pay From savings or insurance (provide evidence for any of the below): worth less than 3 months of your pay worth 3 to 6 months of your pay worth 6 to 12 months of your pay worth more than 12 month of your pay If this applies to you, you must provide evidence such as an insurance policy document which would pay your Capital One credit card payments, banks statements or saving records at the time of sale. Other (please tell us more below) Page 3 of 7
SECTION D - HEALTH CONDITIONS D1 When you took out PPI, were you aware of any health conditions which affected your ability to work? You must provide evidence of the condition(s) you have suffered such as confirmation from your doctor or hospital records at the time of sale. D2 If yes, please explain what the condition was/is and how it affected your ability to work? D3 Have you ever been off work with this condition for 30 consecutive days or more since the PPI was sold? D4 If yes, please provide the start and end' dates of all occasions below. You must provide evidence of the condition(s) you have suffered such as confirmation from your doctor or hospital records at the time of sale. Page 4 of 7
D5 Have you ever attempted to make a claim on the PPI? D6 If yes, was it a successful claim? D7 If your claim was declined due to a pre-existing medical condition please tell us about this and provide us with any evidence you may have. Please enclose copies of any paperwork you received from AXA Insurance UK PLC, or London General Holdings Ltd (LGH) who are now The Warranty Group about this claim. Page 5 of 7
SECTION E: ABOUT YOUR COMPLAINT E1 Why do you feel PPI was mis-sold? Please give as much detail as possible. For example, please tell us any details you remember about: How the sale took place; The information you were given before you took out PPI; How the cost, benefits and terms of PPI were explained to you; The questions you asked before taking out PPI; and Why you decided to take out PPI. Page 6 of 7
SECTION F - YOUR DECLARATION I certify I want to make a formal complaint about the sale of PPI. I certify that all the information I have given in the questionnaire is true and accurate to the best of my knowledge. YOUR SIGNATURE DATE D D M M Y Y Y Y Please note if your name is different to that which you had when you had your Capital One card please provide us with your old and new signature along with a copy of the relevant documents to support the name change - for example: Marriage certificate. Deed poll certificate. Decree absolute. IMPORTANT INFORMATION BEFORE YOU SEND US YOUR FORM Make sure you have: Completed all sections and answered all the questions to the best of your ability. Signed the form. Provided a daytime telephone number in section A1 in case we need to contact you. If required you should include the following evidence: POST YOUR FORM Please return your completed form to: Capital One P.O. Box 5281 ttingham NG2 3HX Sick pay allowance from your employer at the time of sale. Savings / insurance policies that covered your Capital One repayments at the time of sale. Health conditions you suffered at the time of sale. Any previous claims made. Self employment at the time of sale. Name change. If you re sending additional documentation, please only send copies as we re unable to return original documents. Page 7 of 7