Free Boiler Application Form

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Free Boiler Application Form

Your Data Is Stictly Confidential And Will Only Be Used For The Sole Purpose Of Obtaining Government Funded Grants – We Do Not Sell On To Other Parties.

Free Boiler Survey

Step 1 of 12

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Which Benefit Do You Receive?*
- Pension Credit
- Housing Benefit
- Tax Credits
- Job Seekers / Income Support
- Child Benefit
- Employment & Support Allowance
- Universal Credit
- No Benefits -Low Income Applicant

Do You Own The Property ?*
- I Am The Home Owner
- I Live With The Home Owner
- Private Rented - NOT ELIGIBLE
- Council / Housing Association -NOT ELIGIBLE
HOMEOWNERS ONLY CAN APPLY FOR A BOILER

What Is Your Existing Boiler Type ?*
- We Have A Wall Hung Boiler
- I Have A Back Boiler Behind The Fire
- No Heating System Fitted

Is Your Boiler Over 18 Years Old ?*
- Yes My Boiler Is Over 18 years Old
- Unsure Of Boiler Age
- Boiler Is Under 18 Years Old
Boilers Under 18 Years Old Are REJECTED. Back Boilers Can Be Any Age

What Is The Model Of Your Boiler*

What Fuel Does Your Boiler Use ?*
- Mains Gas
- Oil
- LPG

What Is Your Property Type*
- Semi Detached House
- Detached House
- Detached Bungalow
- Semi Detached Bungalow
- Mid Terraced House
- End Terraced House
- Flat / Maissonette
- Park Home

How Many Bedrooms Do You Have*
- One Bedroom
- 2 Bedrooms
- 3 Bedrooms
- 4 Bedrooms +

Please Enter Your Postcode*
House Number AND Ist Line Of Address*

Benefits Claimant Full Name*
Benefits Claimant Date Of Birth*

Your Phone Number*
2nd Phone Number OR Email Address*

Best Time To Phone You To Book Your Free Survey*
- Any Time
- Morning
- Afternoon
- Early Evening
Please Do Not Submit This Form If You Are Not Contactable By Phone GENUINE APPLICANTS ONLY PLEASE

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