Boiler Application Form

- Step 1 of 3

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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Are you currently a ?

• Homeowner
• Renting privately
• Social housing tenant

Select the Benefits You Are Receiving?

• Child benefit – Depends on your income
• Child tax (CTC)
• Employment & Support Allowance (ESA)
• Housing Benefit
• Jobseekers Allowance (JSA) -Income based
• Pension Credit Savings Credit
• Pension Credit Guarantee Credit
• Universal Credit
• Working Tax Credit

Child benefit income assessment has to be carried out to qualify for funding

GDPR Agreement *

• I consent to having this website store my submitted information so they can respond to my inquiry.

Next

Is there a gas connnection to the Property?

• Yes
• No

Was your gas Meter Installed Before April 2022?

• Yes
• No

Current main heating system

• Gas central heating
• LPG central heating
• Electric heating
• Renewable heating
• Oil central heating
• Infrared central heating

Secondary heating system

• Electric panel or oil room heater
• Storage heaters
• Solid fuel fires
• None

What is your boiler type?

• Combi Boiler
• 1960 to 1980 back boiler
• Condenser boiler

Next

The make and model of your boiler?

if known and year of installation ( option )

Do you have a separate hot water cylinder?

• Yes
• No

Does your property have a loft or a room in the roof?

• Yes
• No

Is the loft insulated?

• Yes
• No

What is your property type?

• Detached
• Mid Terrace
• Bungalow
• Semi-Detached
• Maisonette
• Flat

What is the wall Type

• Solid brick wall
• Stone wall
• Cavity wall
• Unsure / Other

Do you have any wall insulation?

• Filled Cavity
• Internal wall insulation
• External wall insulation
• No insulation / Unsure

What is your current heating system? *

• Electric underfloor heating
• Gas central heating from boiler
• Solid fossil fuel fire / open fire
• Wood/blomass heating
• No heating in place
• Electric storage heaters
• Gas fire / back boiler
• Boiled LPG Heating
• Oil heaters

Submit