Title Page
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Conducted on
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Prepared by
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Customer Name
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Location
Customer Details
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Customer Title and Full Name (including any middle names)
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Customer Home Phone Number
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Customer Mobile Phone Number
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Customer Email
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Customer Address (incl post code)
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Customer Date of Birth
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Tenancy (Single/Joint)
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Tenancy Type (C/HA/P)
Tenancy Details
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Date Tenancy Started
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Can you provide a copy of your tenancy agreement?
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How much is your rent? (amount and frequency)
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Are you in arrears with your rent?
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Value of arrears (£)
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Name of Landlord
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Landlord phone number
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Landlord Email
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Landlord Address
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Type of Property
- Bungalow
- Cottage
- Detached
- Mid terrace
- End terrace
- Flat
- Semi-Detached
- Other
Defect Details
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Please describe the property defects in detail
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When did you notice the defect? (date)
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How many rooms does the defect affect?
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Have you reported this to the landlord?
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What date did you report this to your landlord?
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Did your landlord respond? If so provide dates and details of what was communicated.
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Provide photo evidence of the landlord correspondence if possible
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How many times have you contacted the landlord regarding the defects?
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Provide a list of dates and correspondence details sent to the landlord if possible
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Describe in detail how the defects are affecting you and your family's daily routine.
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Has your health been affected by the defects?
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Have any of your family members' health been affected by the defects
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Please provide names and dates of birth of those affected
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Please detail the symptoms each of those affected are suffering
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Have you sought medical attention regarding the heath issues experienced?
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Have any of your belongings been damaged by the defect/s to the property
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If yes, please provide details of the items, how they have been damaged and the cost of the item.
Property photos and media
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Upload full photographic evidence of the defects to the property
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Upload video of property damage
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Assessors Signature
