Fill in the form below to make a claim Date of Birth Tenancy Details Date Tenancy Started Can you provide a copy of the tenancy agreement YesNo Upload Documents ❌ ❌ How much is your rent WeeklyMonthly Are you in arrears with your rent YesNo Value of Arrears WeeklyMonthly Have you ever had court proceedings against you YesNo Who is your landlord SelectLocal AuthorityHousing AssociationPrivate Landlord Landlord details Name of Landlord Landlord Email Landlord Address Landlord Contact Number Type of Property BungalowCottageDetachedTerraceEnd of TerraceFlat Number of bedrooms 12345 Defect Details Defect details moulddamproof leakelectrical hazardwater leak and blocked pipesinadequate heating and/or no hot waterblocked drainsstructural defects Please note defect in your own words What caused the defect? When did you first notice the defect? How many rooms does the defect affect? 12345 Have you reported this to your landlord? YesNo When did you first report this to your landlord? Did your landlord response to you reporting the defect? YesNo If your landlord responded do you have a copy of the response? YesNo Upload Documents ❌ ❌ Has the defect been rectified? YesNo How are the defects affecting you and your family’s daily routine Has your health been affected by the defects? YesNo Are there any other family members of the household claiming for ill health due to the defects? YesNo Name Date of Birth Your Health and Losses What symptoms are you or your family suffering as a result of the defects? Have you been to your GP or sought medical attention? YesNo SelectGPWalk in centreHospital Have any personal effects been damaged by the defect? YesNo Please provide a list of personal items, receipts and cost of items ❌ ❌ Have you previously instructed solicitors regarding this claim or received any historic compensation? YesNo By ticking this the following box, I am giving HD Claim consent to process my personal data for the purposes of this enquiry and understand that I may be contacted by one of HD Claim’s partner solicitors.
