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Free Insulation Application Form

Free Loft Insulation 1

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.

Please Do Not Apply If You Are Not Contactable By Phone !

Free Insulation - Survey

Step 1 of 12

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Do You Receive A Benefit ?*
- Universal Credit
- Pension Credit
- Tax Credits
- Job Seekers / Income Support
- Child Benefit
- Employment & Support Allowance
- Housing Benefit
- No Benefits - MIDLANDS POSTCODES ONLY

Please Confirm You Would Like A Free Heating & Insulation Check*
- I Would Like Heating & Insulation Checked
You Need To Have Both Heating & Insulation Upgraded To Improve Your EPC Rating To Ge A 100% Grant

What Is Your Main Heating?*
- Gas Boiler & Radiators
- Back Boiler Behind The Fire
- Electric Storage Heaters
- Coal Fire
- Warm Air System
- Lpg Boiler
- Oil Boiler
- Gas Fire Only
- No Heating Fitted

How Old Is Your Current Heating*
- Under 10 Years Old
- 10 - 17 Years Old
- Over 17 Years Old
- Unknown

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

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

Do You Own The Property ?*
- I Am The Home Owner
- I am The Landlord
- I Am The Tenant
- Council / Housing Association -NOT ELIGIBLE
- Shared Ownership

Do You Have A Gas Meter Fitted?
- We Have A Gas Meter
- No Gas Meter Fitted
- Dont Know

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

Applicants Full Name*
Applicants Date Of Birth*

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

Please Provide A Password*
Please provide us with a password to assist you properly Favourite Pet Or Favourite Group. Thank you.
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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