Assets for Life Application Form

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Independent Adjudication for Customers

Assets for Life Application Form

What is this application for?
- This application form is for a customer to bring a claim against a company
  which subscribes to CEDR either directly or by membership of a trade or
  membership body.
- Customers may apply if they have not been able to resolve the complaint
  directly with the company.
- The application form will ask you for the details needed to understand what
  you would like the company to do and to help an adjudicator decide your
  dispute.
- The outcome of this adjudication will be contractually binding on both parties if the customer chooses to accept the findings of the adjudicator
What do I need to do?
- Please read the Scheme Rules carefully before you complete this form.
- 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 to get all your facts together, but having all the information will help us assess your case fairly.
- This process is conducted entirely in writing. You must ensure that you provide sufficient information and supporting evidence to substantiate your claim.
Before you can make an application you must:
- First use and exhaust the company’s own internal complaints procedure.
- Come to CEDR within 12 months of receiving the company response.
- Ensure you have read and understood the adjudication process and Scheme Rules fully.
Please let us know if you have any practical needs where we could help – for example with information in another format (e.g. larger print, another language, etc.). If you require assistance in completing this form please contact us.

PDF Application Form Available

If you require a printable version of the application form, to post to us, please click here. We can also send you a paper version, please email applications@cedr.com to arrange this.

If you would like to post your application in, please download the PDF application form above.

You can send applications to:
CEDR Services Ltd
100 St. Paul's Churchyard
London
EC4M 8BU

Assets for Life Application Form
1. About you (the Customer)

Please provide your full contact details.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Email*
example@example.com
Telephone

Area CodePhone Number
Membership number
2. Representation
Are you applying on behalf of someone?

YesNo
If you have a representative acting for you, please provide their details below.
Name

First NameLast Name
Organisation
If applicable
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Email
example@example.com
Telephone

Area CodePhone Number
To be signed by the applicant named in section 1. I hereby give my authority for the above named person to represent me:

Clear
Type your name

First NameLast Name
Date

DayMonthYear

3. Company details
Company*
Address

Street Address

Street Address Line 2

TownCounty

Postcode
Email
example@example.com
Phone Number

Area CodePhone Number
4. Issues in dispute
Please tell us what service or event you complained to the Company about.*

0/1500
Date the service was provided:

DayMonthYear
Date you first complained to the Company:

DayMonthYear
5. What actions would you like the Company to take?
Tick all boxes that apply

Give you an apologyGive you an explanationTake some practical actionOther
Please specify:

0/1500
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.
Total claimed:
£
Please attach any supporting evidence.

Limit: 10 files
Cancelof

7. Declaration
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.

For more information on our privacy practices and commitment to protecting your privacy, please view our Privacy Policy.
Please read the statements below and tick all boxes 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 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.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.
Signature*

Clear
Type your name*

First NameLast Name
Date*

DayMonthYear
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Please verify that you are human*
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Independent Adjudication for Customers

Assets for Life Application Form

What is this application for?

What do I need to do?

Before you can make an application you must:

PDF Application Form Available

Assets for Life Application Form

1. About you (the Customer)

2. Representation

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. Declaration