Benenden Health Scheme Application Form

Section 1

This application form is for customers to bring a claim against Benenden Health. The application form will ask you for the details needed to understand what you would like the company to do and decide your dispute. Applications can only be accepted after you have given Benenden Health a period of at least 8 weeks in which to address your complaint, or at any time after Benenden Health communicates to you that they have reached deadlock.

What do I need to do?:
- Read the Rules and the Guidance for Customers fact sheet. If you are unsure of how to answer a question please contact CEDR for guidance.
- Fill in the application form giving as much information as you can
- It may take you some time to go through the application form and get all your facts together but having all the information will help us assess your case fairly
- You must provide evidence to prove your claim.

1. About you
Full name*
Organisation (if applicable)
Address*
Address 1 Address 2 Town/City Post code
Email address*
Please note that we will correspond with you about your complaint by email.
Telephone number
Membership Number
Representative
Do you need a representative to complete the form on your behalf? Please confirm below
- Yes (if Yes please proceed to 2. Representative)
- No (if No, go to 3. Your Dispute)

2. Representative
You may elect to have a representative act for you (at your own cost). If you choose to do this, provide their full contact details below.
Full name
Organisation (if applicable)
Email address
Please note that we will correspond with you about your complaint by email.
Telephone number
3. Company Details
Company
Address*
Address 1 Address 2 Town/City Post code
Email address

4. Issues in Dispute
Please provide some information on the service(s) that your dispute relates to.
Detail of your issue in dispute
In the space above, please give us as much relevant information as you can about your issue in dispute.
Date Service was Provided
Date you first complained to the Company:
Date you referred the matter to the Financial Ombudsman:

5. What actions would you like the Company to take?
What actions would you like the Company to take?
(Tick all the boxes that apply)
- Give you an apology
- Give you an explanation
- Take some practical action
Please give more information here

6. What Redress are you claiming and why?
If you are asking the adjudicator to order the company to carry out some work or to order compensation then you must specify the details and likely cost in this application and provide evidence to justify the redress claimed. Please ensure you record everything in this application as you cannot change these details at a later date. Please break down your claim by providing a value for each item you are claiming for and provide the reason why you are claiming that amount.
6.1. Pay you compensation
- Yes
- No

Item	Amount Claimed
Describe item here	Insert figure here (£)

7. Customer Declaration
If you are asking the adjudicator to order the company to carry out some work or to order compensation then you must specify the details and likely cost in this application and provide evidence to justify the redress claimed. Please ensure you record everything in this application as you cannot change these details at a later date. Please break down your claim by providing a value for each item you are claiming for and provide the reason why you are claiming that amount.
Data Protection Act The Data Protection Act allows subscribing Companies, trade and membership bodies to provide information and/ or documents about you to CEDR and CEDR adjudicators with your consent. By completing this form you are giving your consent.
Your Declaration*
Please read these declarations and tick all three boxes to confirm you understand them before signing this form.
- I apply to CEDR to appoint an adjudicator to settle this dispute in accordance with the Scheme Rules.
- I have the authority to commit to adjudication.
- I have tried to resolve this matter through the Company’s complaints procedure
- I I understand that it is my responsibility to provide evidence and documents supporting my claim.
- I understand it is my responsibility to read the Scheme Rules and, if necessary, seek guidance from CEDR
- I have not previously referred this dispute to the Courts or other forum (excluding FOS).
- I understand the claim cannot exceed the limit detailed in the Scheme Rules.
- I understand that the adjudicator’s decision will be contractually binding on both parties if I accept it.
Full Name
Your Signature
Date

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Benenden Health Scheme Complaint Form

Step 1 of 7 - Section 1

Section 1

What do I need to do?:

1. About you

2. Representative

3. Company Details

4. Issues in Dispute

5. What actions would you like the Company to take?

6. What Redress are you claiming and why?

7. Customer Declaration