HDR Claim Form,
Client name
*
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
Address
Email Address
*
Phone Number
*
Rent Paid
Monthly
Yearly
Rent Amount
Receiving Benefits
Yes
No
Arrears Payment Plan
Yes
No
When did the issue started
Reported to Landlord
Yes
No
Number of Times Reported
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
Areas Affected
Disrepair Details
Personal Property Damage
Areas Affected
Disrepair Details
Personal Property Damage
Areas Affected
Disrepair Details
Personal Property Damage
Affected Area
Disrepair Details
Personal Property Damage
Health Affected
Client name
*
Date of birth
Medical Evidence
Yes
No
Health Affected
Daily Routine Affects & Personal Losses
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