What best describes your housing status? *

Homeowner

Private Tenant

Private Landlord

Social Tenant

What type of property is it? *

Detached House

Semi-detached House

Mid-terrace House

End-terrace House

Bungalow-detached

Bungalow-semi detached

Bungalow-mid terrace

Flat or Maisonette

Park Home

Anyone in your household on any income-related government benefits? *

Yes

No

Please select all the benefits that apply and continue-> *

Income Support

Housing Benefit

Universal Credit

Income Based Jobseekers Allowance

Pension Credit Guarantee Credit

Working Tax Credit

Child Tax Credit

Income related Employment & Support Allowance

Pension Credit Savings Credit

Child Benefit

None of the Above

Is the total household income less than £31,000 a year? *

Yes

No

Does anyone living at the property have any of these health conditions? -SELECT JUST ONE OPTION *

Cardiovascular

Respiratory

Immunosuppression

Limited Mobility

None of the Above

What's the mains source of heat in your property? *

Mains Gas

Electric

Oil

LPG

Solid Fossil Fuel

No Mains Heating

How many bedrooms? *

1 Bedroom

2 Bedrooms

3 Bedrooms

4 Bedrooms

5 Bedrooms

6 + Bedrooms

What type of wall(s) do you have? *

Solid

Cavity

Both

Don't Know

1st Line of Address *

2nd Line of Address (Optional)

Town/City *

Postcode *

County *

Last steps...

First Name *

Last Name *

Date of Birth (dd/mm/yyyy) *

How do we contact you to confirm your eligibility?

Mobile Phone Number *

Your BEST Email Address *

By providing my contact information, I agree to be contacted by you (and your installation company asscociates and partners) so that my eligibility can be confirmed, a survey booked and an installation date set as per your Privacy Policy .

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