Tenant Details Tenant Name(Required)
First
Last
Address(Required)
Tenant Phone(Required)
Tenant Email
Tenant Date of Birth(Required) Defendant Details Landlord Name:(Required)
Landlord Address
Landlord Phone Number :
Landlord Email :
Tenancy Details Please capture all tenancy details
Tenancy Start Date How Much Rent Do You Pay?
Is This Per Week or Month? Per Week Per Month
Any Rent Arrears(Required) Yes No
Rent Arrears Amount:
If the rent arrears is more than £1000 we cannot take on this case.
Tenancy Type(Required) If it is a joint tenancy then both tenants need to sign the relevant forms.
Tenant Details
Important Information Have you or anyone at the property suffered any illness due to the disrepair that your doctor is aware of? No Yes
Please provide more details of illness
Has the Landlord ever tried to take any action against you? Possession proceedings, anti-social behaviour etc. No Yes
Please provide more details
Are you subject to a debt relief order or bankruptcy? No Yes
Please provide more details
Do you have any shared ownership of the property? No Yes
Have you contacted any other solicitors in relation to the disrepair?(Required) No Yes
If another solicitor is involved, we cannot deal with this client's claim. Advise client to contact the existing solicitor. Disrepair Details Disrepair
It is advisable to list the disrepairs as reported by the tenant. Where the exact date of the notice is not available, please enter an approximate date.
Special Damages Special Damages are items that have been damaged as a result of the disrepair. We will need receipts and images of the damaged items.
Special
Housing Health and Safety Rating System These are health and safety questions that we need to address with the tenant. If any of these items are present then please provide further information. Only brief details are needed. Where possible, please take images.
1. Damp and Mould Growth No Yes
Dust mites and the presence of mould or fungus can lead to a range of health threats commonly associated with damp, humid and mouldy conditions.
Issues include the triggering of various allergies, asthma and the various effects of mould and fungal infection toxins.
Please provide more information
2. Excess Cold No Yes
Cold temperatures indoors can be just as damaging as cold temperatures outdoors. A healthy indoor temperature is 18-21°C.
Respiratory conditions such as flu, pneumonia and bronchitis can be caused or aggravated by cold temperatures, and they can also increase the risk of cardiovascular conditions like strokes and heart attacks
Please provide more information
3. Excess Heat No Yes
High indoor temperatures with no regulation measures can be highly damaging.
They can lead to dehydration, heatstroke, cardiovascular and respiratory issues.
Please provide more information
4. Asbestos and Manufactured Mineral Fibres No Yes
Asbestos and Manufactured Mineral Fibres, which were formerly used to insulate buildings, are notorious factors in the development of respiratory problems.
Asbestos can cause significant damage to lungs, including lung cancer, while MMF can cause damage to skin, eyes and lungs.
Please provide more information
5. Biocides No Yes
Some chemicals which are used to treat timber and mould growth can cause significant issues to building occupants’ health.
There is a risk from breathing the chemicals in, any contact they might have with bare skin and swallowing of the chemical.
Please provide more information
6. Carbon Monoxide and Fuel Combustion Products No Yes
Faulty boilers, among other things, can lead to excess levels of carbon monoxide in a property along with nitrogen dioxide, sulphur dioxide and smoke.
Excess amounts of the above gases can cause dizziness, nausea, headaches, disorientation, unconsciousness, breathing problems and death.
Please provide more information
7. Lead No Yes
Lead ingestion from paint, water pipes, soil and fumes from leaded petrol can cause lead poisoning.
Lead poisoning can cause nervous disorders, mental health issues, infertility, blood production issues and death.
Please provide more information
8. Radiation No Yes
Radon gas, which comes from the natural breakdown of uranium in soil, can enter a home through a basement or cellar floor in an airborne state, but also dissolved in water.
Exposure to radon daughters has been linked to the development of lung cancer
Please provide more information
9. Uncombusted Fuel Gas No Yes
Fuel gas escaping into the atmosphere within a property displaces the oxygen in the air and makes it difficult to breathe.
It can lead to suffocation, unconsciousness, brain damage and death.
Please provide more information
10. Volatile Organic Compounds No Yes
Fuel gas escaping into the atmosphere within a property displaces the oxygen in the air and makes it difficult to breathe.
It can lead to suffocation, unconsciousness, brain damage and death.
Please provide more information
11. Crowding and space No Yes
There are many hazards associated with the lack of space needed for normal living, sleeping and general household life.
A lack of space can cause psychological distress and mental disorders in addition to increased risk of hygiene issues, accidents and personal space and compromised privacy
Please provide more information
12. Entry by Intruders No Yes
A property must be kept secure against unauthorised entry in terms of entry and exit points.
Associated hazards here include fear of burglary occurring, stress and anguish caused by burglary and any injuries caused by an intruder.
Please provide more information
13. Lighting No Yes
Inadequate natural or artificial light can cause physical and psychological harm.
Physical issues include eyestrain; mental problems can include depression due to a lack of natural light.
Please provide more information
14. Noise No Yes
Exposure to noise within the property can cause physical and psychological damage.
Issues include problems resulting from a lack of sleep, poor concentration, headaches and general anxiety.
Please provide more information
15. Domestic hygiene, pests and reuse No Yes
Health hazards here relate to poor design and layout which make it hard to keep a property clean and hygienic, therefore attracting pests, and inadequate and unhygienic provision for storing household waste.
Potential health issues include stomach and intestinal disease, infection, asthma, allergies, disease from rats and physical hazards.
Please provide more information
16. Food safety No Yes
Poor facilities provided for the storing, preparation and cooking of food can cause significant hygiene issues.
Health problems stemming from inadequate food safety include stomach and intestinal disease, diarrhoea, vomiting, stomach upset and dehydration.
Please provide more information
17. Sanitation and drainage problems No Yes
Poor facilities to promote personal hygiene, including personal and clothes washing facilities, sanitation and drainage, can mean increased threat of infections and threat to mental health.
Specific problems can include stomach and intestinal disease, skin infections and depression.
Please provide more information
18. Water Supply No Yes
Water contamination by bacteria, parasites, viruses and chemical pollutants causes a significant risk to health when the water is used for drinking, cooking, washing and sanitation.
Threats posed include dehydration, fatigue, headaches, dry skin, bladder infections, cholera and Legionnaires’ Disease.
Please provide more information
19. Falls associated with baths No Yes
Falls associated with a bath, shower or similar facility can cause a range of physical injuries.
Some injuries include cuts, lacerations, swellings and bruising.
Please provide more information
20. Falls on level surfaces No Yes
Falls on any level surface denote falls indoors, in gardens and on paths, including falls associated with trip steps, thresholds or ramps where the change in level is less than 300mm.
Some injuries include bruising, fractures, head, brain and spinal injuries.
Please provide more information
21. Falls associated with stairs and ramps No Yes
Falls associated with stairs and ramps denote falls where the change in level is greater than 300mm. They include internal stairs or ramps within a property, external steps or ramps associated with the property, access to the property and to shared facilities or means of escape from fire, and falls over stairs, ramp or step guarding.
Some injuries include bruising, fractures, head, brain and spinal injuries.
Please provide more information
22. Falls between levels No Yes
Falls between levels denote falls from one level to another, inside or outside a dwelling where the difference is more than 300mm. They include falls from balconies, landings or out of windows.
Some injuries include bruising, fractures, head, brain injuries, spinal injuries and death.
Please provide more information
23. Electrical Hazards No Yes
There are many electrical hazards associated with faulty equipment or exposed wiring. Injuries include electric shocks, burns and potentially death in the case of strong currents or prolonged exposure.
Please provide more information
24. Fire No Yes
Uncontrolled fire and associated smoke present various threats to health, including injuries from clothing or hair catching fire.
Some injuries include smoke inhalation, burns and death.
Please provide more information
25. Flames, hot surfaces and materials No Yes
Injuries caused by contact with a hot flame or fire, hot objects and non-water-based liquids are common. Scalds are caused by contact with hot liquids and vapours.
Injuries include burns, scalds, permanent scarring and death.
Please provide more information
26. Collision and Entrapment No Yes
There is a risk of physical injury from trapping body parts in architectural features, e.g. trapping fingers in doors and windows and colliding with objects such as windows, doors and low ceilings.
This can result in physical injuries such as cuts and bruising to the body.
Please provide more information
27. Explosions No Yes
There is a physical injury risk from the blast of an explosion, from debris generated by the blast and from partial or total collapse of a building as a result of the explosion.
Health hazards include physical injuries, crushing, bruising, puncture, fractures, brain injuries, spinal injuries and death.
Please provide more information
28. Ergonomics No Yes
There is a risk of physical strain associated with functional space and other features at the dwelling. Injuries include strains and sprains.
Please provide more information
29. Structural Collapse and Falling Elements No Yes
Inadequate fixing, disrepair or adverse weather conditions can lead to the threat of the dwelling collapsing or part of the fabric being displaced or falling.
Health threats include various physical injuries and death.
Please provide more information
Agent Checklist Please go through this checklist to ensure you have obtained everything for this client before you submit this form.
Enter Agent Name(Required)
Please enter your full name.
Contract Signed(Required) Yes No
Please ensure the CFA is signed and sent to us iof this case is accepted.
Form of Authority Signed(Required) Yes No
Please ensure the form of authority is signed and sent to us if this case is accepted.
Client ID and Proof of Address Obtained(Required) Yes No
Please obtain a form of authority and proof of address for the clients
Tenancy Agreement(Required) Yes No
Where possible please obtain a copy of the tenancy agreement.
Images uploaded(Required) Yes No
Please upload the images to Google Drive or Dropbox and send the link by email.
Joint Tenancy Documents(Required) Yes No NA
If this is a joint tenancy, have both tenants signed the documents?