Start Claim Request Form Have you sought legal advice on your property before?- Select -YESNOIf, your answer is yes then what was the name of your previous solicitors?PreviousNextTENANT/OCCUPIERS DETAILS:TitleMrMrMrsMissTenant’s Full Name: Tenant’s Full Postal Address: Tenant’s Date of Birth: Tenant’s National Insurance Number: Tenant’s Telephone Number: Tenant’s E-mail Address:Tenant’s Occupation:TENANCY DETAILSTenancy Type: Single Tenancy Joint Tenancy Private TenancyTenancy Commencement Date:Does The Tenant Have a Copy of The Tenancy Agreement?- Select -YESNOWhat is the Tenant’s Rent Per Week/Per Month?Is the Tenant in Any Rent Arrears? - Select -YESNOIf Yes, How Much?Has the Landlord ever Started Possession Proceedings on the Property?- Select -YESNOIf, yes then on what date?Landlord Name:Who is your landlord?Are you Currently Living in the Property?- Select -YESNOWho else lives in the Property with you?What is the Type of Property? Studio Apartment Flat Bungalow Terraced House Semi-detached House Detached HouseNumber of Bedrooms in the Property?What Floor is the Property On?Is the Flat Directly Under the Roof?- Select -YESNOPreviousNextDISREPAIR ISSUES - EXTERIORIs there any Exterior Disrepair?- Select -YESNODISREPAIR ISSUES – THROUGHOUT THE PROPERTYIssue 1 Rising Damp Mould/Condensation Leaking Water Unsafe Flooring and Staircases Structural Cracks Insect and Vermin InfestationLocation of Disrepair? Kitchen Bathroom Living Room Bedroom 1 Bedroom 2 HallwayWhen did the Issue First Occur? Boiler/Central Heating Issues Asbestos No Running or Hot Water Electrical Issues Rotting Windows and Door Frames Insect and Vermin InfestationWhen did you first report this to your landlord?How would you rate your disrepair?Comments:Issue 2 Rising Damp Mould/Condensation Leaking Water Unsafe Flooring and Staircases Structural Cracks Insect and Vermin InfestationLocation of Disrepair? Kitchen Bathroom Living Room Bedroom 1 Bedroom 2 HallwayWhen did the Issue First Occur? Boiler/Central Heating Issues Asbestos No Running or Hot Water Electrical Issues Rotting Windows and Door Frames Insect and Vermin InfestationWhen did you first report this to your landlord?How would you rate your disrepair?Comments:PLEASE CONFIRM WHO REPORTED THESE ISSUES TO YOUR LANDLORD AND HOW Client Family Member Social Worker Other By Telephone By E-mail In Person OtherHOW MANY TIMES HAVE YOU CONTACTED YOUR LANDLORD DURING THE PERIOD OF DISREPAIR?Number of Correspondence? By Telephone By E-mail In Person OtherComments:DETAILS OF ANY REMEDIAL WORKS DONE BY THE CLIENT INCLUDING THE DATE AND COSTComments:HOW MANY TIMES HAVE SURVEYORS/WORKMEN VISITED YOUR PROPERTY AND WHAT HAVE THEY SAID/DONE?Number of Visits?Please confirm any remedial works done by your landlord including the date and whether these were effective?Comments:PreviousNextTHE EFFECTS OF THE DEFECTS ON YOU AND YOUR FAMILYWe need to know how you and your family were affected by the defects, which will include, for example:The nature of the inconvenience or discomfort resulting from the defect (e.g., unable to use the lounge for six months, ashamed to invite friends and relatives around etc).The effect on the physical health of you and your familyThe effect on the mental health of you and your familyHAVE YOU VISITED YOUR GP OR A HOSPITAL DUE TO YOUR HOUSING DISREPAIR? YES NOIf, Yes then when?FINANCIAL LOSSYou may have suffered financial loss as a result of the defects which include: Increased heating costs, in which case please let us know: Type of heating used Rooms affected Period of claim Cost in previous comparative period (e.g., previous winter when there were no defects) Copies of all bills for the period of claim and previous comparative period Specific items damaged, e.g., furniture, carpets, clothes, etc. Redecoration costs – please let us know: Which rooms were affected? Date of redecoration costs (with receipts if possible) Any other financial losses and expenses such as increased telephone bills, travel, cleaning expenses, costs of eating out of the home. Where possible please provide receipts or bills.Comments:MISCELLANEOUSComments:FOR OFFICE USE ONLY No Win No Fee Discussed 50% Success Fee Discussed CFA Discussed Client ID Requested External Pictures of The Property RequestedDate of Instructions: Previous SUBMIT FORM
