Name:

Email:

Date of Birth:

Postcode:

Account Provider Name (Bank / Building Society / Credit Company):

Account Number:

How did you take the finance out?
in a meetingvia telephonevia postvia internetdon't know

Did you take out the finance to settle off other debts?
yesnodon't know

What was your employment status at the time you took out the finance?
full time employedpart time employedself employedcontractingretiredunemployeda student

If you were employed, what was your job title and the name of your employer?

Approximately how long had you been working there?

If your employment status has changed since you took out the insurance, please tell us how (e,g, if you were self employed, but are now employed)?

If you were entitled to sick pay from your employer, for how long would you have been entitled to it?
less than 3 months3 months or more, but less than 6 months6 months or more, but less than 12 months12 months or moreStatutory OnlyNot Entitled / Not Employedother (please tell us more below)

What is your current job title, and the name of your current employer?

What was your reason for borrowing the money (or taking out credit)?
Refinancing or consolidating other debtsBuying a carPaying for home improvementsPaying for a weddingPaying for a holidayNon-essential spending (buying for leisure)Essential everyday spending (for example, rent, household bills, food shopping)Business loanother (please tell us more below)

Would you have had another way of making repayments, such as savings, if you lost your employment?
from savings or insurance; worth less than 3 months of your payfrom savings or insurance; worth 3 months or more, but less than 6 months of your payfrom savings or insurance; worth 6 months or more, but less than 12 months of your payfrom savings or insurance; worth 12 months or more of your paynoneby some other means (please tell us more below)

Were you asked about your medical history?
yesnodon't know

Did you have any pre-existing medical conditions?
yes (please tell us more below)nodon't know

Did you ask for the PPI / Insurance to be added to your finance agreement?
yesnodon't know

Were you told that the PPI / Insurance was optional?
yesnodon't know

Were you told that you couldn't have the finance unless you took the PPI / Insurance?
yesnodon't know

Were you told you could buy PPI / Insurance elsewhere?
yesnodon't know

Was the PPI / Insurance added to your finance agreement without your knowledge?
yesnodon't know

Was the full cost of the PPI / Insurance explained to you?
yesnodon't know

Did you settle your finance early?
yesnodon't know

Did your finance replace existing finance you had with the same provider?
yesnodon't know

Did you have existing PPI / Insurance with another provider when you took the finance out?
yesnodon't know

Are you in arrears with your finance?
yesnodon't know

Are you currently, or have you been, bankrupt, in an IVA or Debt Management Plan?
yesnodon't know

Your provider received commission for selling PPI to you. Had you been made aware that you were paying any amount of commission, would you have taken the policy?
yesno