Title Page
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Client Name
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Prepared by
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Claim type
Client
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Title
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First Name
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Last Name
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Date of Birth
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E-mail
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Contact Number
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Alt. Contact Number
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Address Line 1
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Address Line 2
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Address Line 3
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Address Line 4
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Postcode
Tenancy
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Landlord Name
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Tenancy Start Date
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Do you have a copy of your tenancy agreement?
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Is the tenancy single or joint?
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Joint Tenant First Name
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Joint Tenant Last Name
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Joint Tenant Date of Birth (yyyy/mm/dd)
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Joint Tenant Contact Number
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Joint Tenants E-Mail
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Are you named in the tenancy?
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Did you pay a deposit?
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How much rent do you pay?
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How often is this paid?
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Are you in receipt of housing benefit?
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if so, how much do you receive?
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Do you have any arrears?
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How much arrears ?
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Do you have a payment plan set up?
Property Details
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Property type?
- Flat
- Bungalow
- Terraced
- Semi Detached
- Detached
- Maisonette
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Kitchen Damaged ?
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Details
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Living Room Damaged ?
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Details
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Utility Room Damaged ?
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Details
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Bathroom 1 Damaged ?
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Details
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Bathroom 2 Damaged ?
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Details
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Bedroom 1 Damaged ?
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Details
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Bedroom 2 Damaged ?
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Details
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Bedroom 3 Damaged ?
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Details
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Exterior Damaged ?
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Details
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Other Damages ?
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Details
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Personal Injury or illness due to property conditions ?
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Complaint Details
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Have you complained to the landlord ?
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First complained to landlord ?
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Number of complaints made ?
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Last complained to landlord ?
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Do you have copies of the complaint correspondence?
- Yes
- No
- N/A
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Has landlord responded to complaints?
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Has landlord made repairs?
