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Title
MrMissMrsMsDr

* Forename:


* Surname:


* Email Address:


Telephone (Home):


Telephone (Mobile):


Type of Policy:
Credit/Debit card Personal loan Other loan

What year did you take out your policy?


Policy Provider?


Policy / Account Number:


At the time you were sold the cover, were you self-employed?
Yes    No 

Did you feel pressurised into taking out the policy?
Yes    No 

When you took out this policy, did the sales representative imply that the payment protection insurance was optional?
Yes    No 

Were the exclusions of the policy explained to you?
Yes    No 

Have you tried to make a claim under this policy?
Yes    No 
If so, were you successful?
Yes    No 

Any other additional information: