Energy Survey Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1959
1958
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1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Email
example@example.com
Address
Street Address
Street Address Line 2
City
County
PostCode
Have you had any Government grants in the past?
Yes
No
Homeowner or Renting?
Homeowner
Renting
Landlord Details
If not applicable leave blank
Landford Name(if applicable)
First Name
Last Name
Landlord Address(f applicable)
Street Address
Street Address Line 2
City
County
Postal Code
Landlord Phone Number
Please enter a valid phone number.
House Details
Property Type
Detached
Semi detached
Terraced
Mid terraced
End terraced
Other
Wall Type
Cavity wall
Solid wall
Other
Type of Loft Insulation
Rockwool
Fiberglass
Spray Foam
Part boarded
Fully boarded
Other
How old is the insulation
under 5yrs
5 to 10 yrs
10yrs +
Unsure
Type of heating
Mains Gas
Electric
LPG
Other
Measures Available
Please select the measures that you are interested in
Please select from the following list
Boiler upgrade
Ventilation - kitchen/bathroom
Heating thermostat
Window trickle vents
Loft insulation
Wall Insulation (if qualifying)
Cavity wall (CWI)
Internal wall insulation(IWI)
External wall insulation(EWI)
Required Evidence
Please fill in the relevant boxes and photos
Photo of boiler
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Boiler Make
Boiler Model
Boiler Age
Boiler label Image
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Employment Details Inc Benefits
Employment Status
Retired
Employed
Unemployed
Self employed
Other
Do you receive any of the following benefits?
Universal Credit
Housing Benefit
Income related ESA
Income based Jobseekers
Pension credit
Income Support
Tax credit(child or working)
Not on benefits
Benefit Proof letter
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Household Annual Income
Under 31k
Over 31k
N/A
Health Conditions
Does anyone in your household have a health condition adversely affected by living in a cold home
Yes
No
Qualifying Illnesses - four main categories
1 - Cardiovascular - Angina and other small heart conditions
2 - Respiratory Diseases - Asthma, cronic obstructive pulmonary disease, bronchitis, pneumonia, allergic rhinitis and chronic sinusitis.
3 - Immunosuppression - All types of cancer, diabetes, lupus, multiple sclerosis, inflammatory bowel diseases
4 - limited mobility - arthritis, paralysis, cerebal palsy, parkinsons disease, muscular dystrophy, fibromylgia and spinal cord injuries.
Evidence required
Photo of utility bill dated in the last 3 months
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Photo of council tax bill dated in the last 3 months
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Photo of repeat prescription
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Prescription photo 2
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Referral Name - Please state the name of your referral
*
Submit
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