Once you have completed the below form, our team will asses the application and get in touch to discuss the next steps.

Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People’s Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People’s Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People’s Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweSelect country

Date of Birth *

Date of Birth

Email Address *

Phone *

Confirm Occupancy *

Home OwnerPrivate TenantLandlordCouncil TenantWhat is your relationship to the property you are applying for?

Household IncomeLess than £31kMore than £31kNot SureLess than £31k

House Hold HealthNo Health IssuesHealth ConditionsGP Sign OffNo Health Issues

List of Health Conditions

Household Benefits *

No Benefits PresentJSAIncome SupportPension Credit Guarantee CreditWorking Tax CreditChild Tax CreditUniversal CreditHousing BenefitPension Credit Savings CreditOther BenefitsPlease select all benefits that are currently recieved within this household

Other Benefits

What is the properties EPC ratingUnknownABCDEFGNo EPCUnknown

What is your Property TypeDetached HouseSemi Detached HouseTerraced HouseDetached BungalowSemi Detached BungalowChalet or Park HomeFlatDetached House

What year was your property builtPre 19001901-19401941-19601961-19791980-19981999 +Not Sure / Don’t knowPre 1900

Are your walls insulated?InsulatedNot InsulatedUnknownInsulated

External Wall Type? *External Wall Type?Solid WallCavity WallNot SureExternal Wall Type?

Confirm your Boiler Details *

Is the Property Listed?NoGrade 1Grade 2Conservation AreaUnknownNo

Confirm Prior Works to the property *

Solar PanelsLoft/Roof Insulation (Any)Wall Insulation (Any)Floor Insulation (Any)New Boiler / Central Heating (Any)No Works in last 8 yearsThermalYou must select one or some of the options (if fitted to the property in the last 8 years)

Has this property had ECO Funding before?

YesNoUnknown

Approximate Date of Funding

Confirm the heating type fitted to your property

Solid Fuel (to Radiators)Solid Fuel (no Radiators)Electric Boiler (to Radiator)Electric Panel HeatersElectric Storage Heaters (Old)Electric Storage Heaters (New)LPG (Bulk Tank)LPG (Bottles)No HeatingOil Boiler (unknown)Oil Boiler (non condensing)Oil Boiler (condensing)Mains Gas (boiler unknown)Mains Gas (room heaters)Mains Gas non condensingRenewable heating (biomass, air source etc)Mains Gas Condensing

Free Measure Options (Select what you would like fitted to your Property) *

New Condensing Gas BoilerNew Storage HeatersAir Source Heat PumpLoft InsulationInternal Wall InsulationExternal Wall InsulationFlat Roof InsulationSolar PanelsPlease not that not all measures are suitable and this would be discussed when we complete a free survey.

Additional Property Information

Solid Ground FloorFloor BoardsBasementLoft Insulation (More than 100mm)Loft Insulation (Less than 100mm)No Loft InsulationWater Tank on Boiler?Please select if you have any of the following

Consent and Submit *

I agree to my information provided being shared with the Department for Work and Pensions via the Energy Saving Trust to confirm whether I am in receipt of the relevant benefit(s) to be eligible for the ECO4 and GBIS schemes. I authorise freeboilergrants uk to contact me in relation to funded home improvements from other companies.Please Tick the 2 tick boxes then add your signature below

Signature *

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Upload Photo of boiler/heating source if possible

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