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House Disrepair Claim

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Your Details
Name*
Prefix First Last
Email Address*
Phone*
Address*
Street Address Address Line 2 City County / State / Region Post Code

Tenancy
Tenancy*
Tenancy Type*
Date Tenancy Commenced*
DD slash MM slash YYYY
Can you provide a copy of the tenancy agreement?*
Tenancy Agreement Upload
Drop files here or

Max. file size: 8 MB.
Agreement Provided*
Agreement to be emailed*
How often do you pay your rent*
Weekly Rental Payment*
Monthly Rental Payment*
Are you in arrears with your rent?*
Monthly Rental Payment*
Can you provide the name and contact details for your landlord?*
Name of Landlord*
Landlord Email Address
Landlord's Telephone Number
Landlord Address
Street Address Address Line 2 City County / State / Region Post Code
Type of property

Defect Information
Nature of Defect*
When did you first notice the defect?*
How many rooms does the defect affect?*
Have you reported this to your landlord?
When did you report this to your landlord?*
DD slash MM slash YYYY
Did your landlord respond to you reporting the defect?*
How many times have you contacted your Landlord about your defects*
Can you provide a list of dates and correspondence that you have sent to your landlord?*
How are the defects affecting you and your family’s daily routine*
Has your health been affected by your defects?*
Health affect details*
Are there any other members of the household claiming for ill health due to the defects?*
Please provide names and DOB for all affected family members*
What symptoms are you/they suffering? GP?*
Have any personal effects been damaged by the defect?*
Photos/Sketch plans*
Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, heic, webp, Max. file size: 8 MB.
Please upload any photos, sketches or plans of the property and defects.

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