Page 1
A. Your details
1. You
Title First Name Middle Name Last Name Date of birth
Address*
Post Code
* If you’ve moved address since the time the policy was taken out, and you have an open account with us, please ensure you update your address on our systems.
Otherwise, we may need to verify your identity using information from a credit reference agency, which may involve credit reference agencies checking the details
supplied against any particulars on any database (public or otherwise) to which they have access. They may also use your details in the future to assist other
companies for verication purposes. This will allow us to complete our investigation and write to you with the outcome. This search is only visible to you, and will
have no aect on your credit rating or ability to obtain future credit. This search is automatically removed after 12 months.
* If you’ve moved address since the time the policy was taken out, and you have an open account with us, please ensure you update your address on our systems.
Otherwise, we may need to verify your identity using information from a credit reference agency, which may involve credit reference agencies checking the details
supplied against any particulars on any database (public or otherwise) to which they have access. They may also use your details in the future to assist other
companies for verication purposes. This will allow us to complete our investigation and write to you with the outcome. This search is only visible to you, and will
have no aect on your credit rating or ability to obtain future credit. This search is automatically removed after 12 months.
1
Thank you for supplying your email address. By doing so, you conrm that we can email you about your complaint. Complaint responses may contain
information such as transaction details as well as any general details about the complaint investigation.
By providing your email address, you conrm and accept that any emails sent by us to you won’t be sent in a secured or encrypted format. The Barclays Group
accepts no liability for any damage , loss or disclosure caused by any virus transmitted by this email. E-mail transmission cannot be guaranteed to be secure or
error-free as information could be intercepted, corrupted, lost, destroyed, arrive late or incomplete, or contain viruses. Please be aware that if you are sharing a
mail account or using a company mailbox, your email could be read by a third party.
Barclays Payment Protection Insurance (PPI)
Customer Complaint Form
For Bank Use Only
Our Reference Number Your Account Number
If we’ve written to you about this PPI complaint
already, please give us the Reference Number
from the most recent letter we sent to you
Our Reference Number
Contact Information
We may need to contact you by phone or text message to clarify some details, or to keep you updated on your complaint. To ensure we have the right details, please
provide your contact information below. If you are a Barclays customer, please visit your branch or online banking should your contact details for an existing account
require updating, as updates will not be made from detail provided within this form.
Main Number Alternate Number
Email Address
1
2. Were you living in the UK when you took out your PPI? Yes No
3. Joint complainant
Yes
No
If you selected No, go to next section
Title First Name Middle Name Last Name Date of birth
Address*
Post Code
Joint complainant’s Contact Information
Main Number
Alternate Number
Email Address
1
D D M M Y Y Y Y
D D M M Y Y Y Y
Page 2
B. About the Policy
4. What type of product did your PPI cover?
Personal loan
Business loan
Mortgage Overdraft
Credit Card Loan secured on your home
Not sure
5. What area of Barclays was your product from?
Barclays
Barclaycard
Woolwich Littlewoods
Goldsh Morgan Stanley
Egg
I don’t know
Other
6. Please provide the following details:
Account / Card No.
Sort code
Policy Number Policy start date
7. How did you take out the policy?
Face to face in a branch
Face to Face not in a branch
Over the phone
Through the post
Using the internet
Any other
8. If you had any other policy where your personal circumstances were the same as mentioned
in this form, you can add the details of that policy too:
Barclays Payment Protection Insurance (PPI)
Customer Complaint Form
If your circumstances were dierent for the other policy, then we recommend you to complete a separate form for the other policy
C. About your employment & personal situation
9. When you took out the PPI policy, what was your employment status (please choose from the below)
Full time employed Part time employed 16 hours or more
Part time employed less than 16 hours Temporary/Agency worker
Not working/Unpaid Work
Retired
Director of a company Self employed
Fixed term contract
Student full time education
Student part time education - also employed 16 hours or more
Student part time education - also employed less than 16 hours
Student part time education - not employed
Any other, provide details
10. When you took out the policy, how long had you been in continuous employment?
Years
Months
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Barclays Payment Protection Insurance (PPI)
Customer Complaint Form
C. About your employment & personal situation cont…
11. If you were employed when you took out the policy, please provide details of your job or jobs
Employer Name
Your job role From
To
Employer Name
Your job role From
To
Employer Name
Your job role From
To
Employer Name
Your job role From
To
(If there are more employment details that you want to add, please provide in section 19)
12. When you took out the policy what was your take home pay?
Amount
Per week
month
year
Please tick the appropriate choice
13. When you took out the policy, if your salary stopped, due to sickness or redundancy for example, how
would you have paid for your monthly borrowing?
Please provide details and amounts of any:
• savings
• employer benets including how many months, full and partial, sick pay and redundancy pay?
• insurance policies
• other income
14. Did you have any known medical conditions at the time you took out the policy?
Yes
No
If you selected Yes, please tell us about your condition
The name of your condition
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Barclays Payment Protection Insurance (PPI)
Customer Complaint Form
C. About your employment & personal situation cont…
Your recollection of what the sales material or sales adviser said about your medical condition and your
ability to claim under the policy
You may wish to include your understanding of any policy exclusions that were mentioned during the sale
or in the sales material provided.
D. More information
15. Have you ever made a claim on the policy for periods of sickness or unemployment?
Please provide details of your claim. What was the claim for? Was it successful?
16. Do you currently have or have you ever had an insolvency agreement in place?
Please provide details
• when did the agreement start and has it ended?
• the name and address of your insolvency practitioner or ocial receiver
• the reference number of the agreement
• the type of insolvency (IVA, bankruptcy)
Please note: if you’re in an IVA/Bankruptcy then any refund you may be entitled to may be paid direct to
your Insolvency Practitioner/Ocial Receiver
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Barclays Payment Protection Insurance (PPI)
Customer Complaint Form
D. More information cont…
17. Tell us more about the money you borrowed when you took out the policy?
• why did you borrow the money e.g. to pay bills, to pay for a holiday, to pay o existing debt?
• if you paid o existing debt, how much did you pay o with the borrowing?
18. Please tell us why you are complaining, why you are unhappy with your policy and what you recall about
how it was sold to you. The information you provide here will help us fully investigate your complaint.
• what information were you given before and after you took out the policy?
• how were the policy terms and costs explained to you?
• why did you decided to take out the policy?
19. Please use this section to tell us if there are more details that you want to add.
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Barclays Payment Protection Insurance (PPI)
Customer Complaint Form
E. Declaration
In the event of a refund do you have a specic Barclays account you would like us to credit?
If you’re eligible for a refund and currently hold an active Barclays account, we will credit the account
details you provide. Alternatively, we can send you a cheque.
Account No.
Sort code
Finally please read below and sign this declaration.
Thank you for completing this form. To enable us to investigate your complaint, we require you to sign
below. Please tick the box to sign and agree the following:
I conrm that I want to make a complaint about the sale of all PPI policies described.
I conrm that all the information I’ve given in this form is true and accurate to the best of my
knowledge – and I consent to it being used in the investigation and resolution of my complaint
relating to PPI policies described in this form.
If my details have changed, I consent to an identity check using a credit reference agency – as detailed
in the ‘Your address’ section.
If I’ve included an email address and provided consent, I allow Barclays to contact me and keep me
updated on the progress of my complaint. I have read, understood and accept the risk associated
with the use of email, as outlined. Where I’ve provided an email address for another party I conrm
they’re aware of the security risk involved and agree to be contacted via email.
I consent to Barclays’ use of my information in the manner described in this form and Barclays Terms
and Conditions for Retail Customers and, to the extent I have provided information relating to others,
I conrm that I have their consent – or are otherwise entitled to provide the information to Barclays,
to be used in the manner described.
Please return this completed form directly to us either using the
pre-paid envelope if supplied or to the address below:
Barclays PPI Dept, Leicester LE87 2BB
Privacy policy
The form asks you for personal and nancial details relevant to your relationship with Barclays, Barclaycard, Firstplus, First Data, Littlewoods, Woolwich, Morgan
Stanley, Goldsh, Egg (each and together ‘us’, ‘we’ or ‘Barclays’). The Barclays Group uses and retains details you give about yourself and others to resolve your
query or complaint and for research and statistical analysis to improve our services. We may pass your information collected to people who provide a service to us
or are acting as our agents, on the understanding that they will keep the information condential.
D D M M Y Y Y Y D D M M Y Y Y Y
Date Date
Your signature Joint complainant signature
Page 7
Barclays Payment Protection Insurance (PPI)
Customer Complaint Form Guidance Notes
Why should I complete the PPI Form?
The form is designed to make it as easy as possible for you to submit your complaint about why you feel
your PPI was mis-sold. It’ll help assist us with assessing your complaint thoroughly by helping you provide
relevant information about the sale of your policy and your circumstances. It may be helpful if you have any
relevant documentation available with you when completing the form, for example policy documents, credit
card statements or credit agreements.
Do I need to complete the PPI Form?
You don’t need to complete a form to have your complaint investigated. However, completing it may allow
us to reach a decision more quickly because it asks for comprehensive detail that may not have been
covered in a letter.
If you’re complaining about more than one PPI policy or product and your personal circumstances were
the same at the time each policy/product was sold you only need to complete one form. If your personal
circumstances were dierent you will need to complete a separate one for each.
How long should I expect to wait before I hear about my complaint?
We’ll write to you to acknowledge your initial complaint within 5 working days of receiving it and we’ll
write to you within 8 weeks with our decision. We may need to contact you during this time for further
information. Please note there may be exceptions to this timeline depending upon the information that
is available to us and the nature of each individual complaint.
How to complete the Form
What to do when the Form is completed
Please return the completed form to Barclays PPI Dept., Leicester, LE87 2BB. Before posting, you may
wish to take a copy of your completed form for your own records.
Claims Management Companies (CMC)
You can make your complaint directly to us and don’t need to use a claims management company (CMC).
A CMC will typically charge an up-front fee or take a proportion of any nal payment you may be due.
We’ll assess all complaints sent directly to us in exactly the same way that we treat complaints sent in
by a CMC. Your complaint will not be dealt with dierently or quicker by using a CMC.
If you’ve nominated a CMC or any third party to act on your behalf, you’ll need to settle any fees or
charges with them directly. Please ensure you refer to the terms of your agreement with them.
Your Details
Section A / Q1 to Q3
Completing this section will help us to locate your account and PPI policy. Please also use this
section to tell us your preferred contact information. We’ll use these to get in touch with you if we
need to discuss anything further and to keep you updated.
About your Policy
Section B / Q4 to Q8
This is where you tell us about the policy and the processes that you went through while taking out
your policy. Please try to provide as much detail as possible.
About your
Employment and
personal situation
Section C / Q9 to Q14
This is where you give us the details about your employment during the time you held your PPI
policy. You can also give us the details about any medical conditions you had at the time you took
out your policy and if you were covered by any health benets by your employer or any other policy.
More Information
Section D / Q15 to Q19
This is where you can provide us more details about the policy that can help us make a decision on
your complaint. This also gives you the opportunity to give us the reason that you were unhappy
with the policy or the way it was sold to you.
Declaration
Section E
Please read this section carefully, sign and date it. In this section you are conrming you’ve
provided your bank details (if you choose to do so) and that you’ve included everything you
want to tell us about the complaint. It is important that the form is signed and dated. When
signing the form you are conrming you’d like us to investigate your complaint. You’re also
authorising us to perform any required name and address checks as part of the investigation
into your complaint, and where applicable authorising your appointed third party / parties to
represent you in this complaint.