Letter of Authority
Guidance Notes
Please write clearly in the white spaces with capital letters or cross the boxes. Once complete please submit
or return in the prepaid envelope provided.
1
Your Details
Title
First Name
Initials
Last Name
Date of birth (dd/mm/yyyy)
Contact Number
Email address
------ 2nd Applicant (only complete if joint account) ------
Title
Fi
rst
Name
Initials
Last Name
Date of birth (dd/mm/yyyy)
2
Y
our Address
Addr
ess Line 1
Previous Address (if moved i
n the last few yea
rs)
City
Postc
ode
3
Y
ou
r Claim
Bettin
g Company/Pla tform
Customer’s Username
To whom it may concern
Your
Si
gnature
Main
Ap
plicant
2
nd
Applicant
Date
Date
I/We
he
reby appoint and authorise Ingram Toft to act on my/our behalf with respect to my/our gambling/be
tti
ng
complaint and
claim
for
compensation
on
betting
and
gambling
payments.
I/We
further
authorise
Ingram
Toft
to submit
a
Subject
Access
Requ
es
t on my/our behalf under Section 7 of the Data Protection Act 2018.
I/We
co
nfirm that I/we have lawfully contracted with Ingram Toft and request that you comply with any requ
es
t for
information
they make on my/our behalf, whether by telephone or in writing (including e-mail or online submissions). I/We
confirm that
Ingra
m
Toft have full delegated authority to act on my/our behalf and settle my/our claim without further rev
ert
i
ng to
myse
lf/ourselves. This instruction covers all payments and bets related to all accounts I/we hold with yourselv
es
.
Ingra
m Toft is a trading name of LS Claims Ltd which is
r
egulated by the Financial Conduct Authority in resp
ect of Regulated
Claim
s
Management activities (FCA no: 831386) Registered Office: 13
th
Floor, Piccadilly Plaza, Mancheste
r,
M1 4BT
. Vat No:
287011704.
