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Personal Injury Only
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0121 661 8837
HDR Claims Form
Client full name
*
Address
Email Address
*
Phone Number
*
Date of birth
Joint Tenancy
Single
Joint
Tenancy Agreement Date
Type of Property
Terrace House
Detached House
Semi Detached House
Bungalow
Down Stairs Floor Only
Upstairs Floor Only
Tower House
Full Apartment
Ground Floor Apartment
Upstairs Floor Apartment
Down Stairs Flat
Upstairs Floor Flat
Counsel House
Housing Association
Company House
Rent Paid
Weekly
Monthly
Yearly
Rent Amount
Receiving Benefits
Yes
No
Arrears Payment Plan
Yes
No
When did the issue started approximately
Reported to Landlord
Yes reported to the Council
Yes reported to the housing association
No Not Yet Reported
Number of Times Reported approximately
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Has the Landlord Responded
Yes
No
Reported Last time approximately
Areas Affected
Disrepair Details
Personal Property Damage
Areas Affected
Disrepair Details
Personal Property Damage
Areas Affected more than one
Disrepair Details
Personal Property Damage
Health Affected
Medical Evidence
Yes
No
Daily Routine Affects & Personal Losses
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