Boiler Enquiry Form 1. Personal DetailsName* TitleMrMrsMissMsDrProf.Rev. Prefix First Last Address Street Address Address Line 2 Town/City County Postcode Phone*Mobile Phone*Email* Date of Birth* Date Format: DD slash MM slash YYYY 2. BenefitsIf you are currently in receipt of benefits please tick the appropriate box Armed Forces Independence Payment Carer's Allowance Income-related Employment and Support Allowance (ESA) Income Support Industrial Injuries Disablement Benefit Severe Disablement Allowance Attendance Allowance Constant Attendance Allowance Pension Guarantee Credit Income-based Job Seekers Allowance (JSA) Industrial Injuries Disablement Benefit Personal Independence Payment Tax Credits (Child Tax Credits and Working Tax Credits) War Pensions Mobility Supplement 3. Property DetailsType of property?Semi-DetachedDetachedTerracedMid TerraceEnd TerraceFlatCottageBungalowOtherPlease specify the type of property you have*How many bedrooms does the property have?Please Select123456 or moreDoes the property have a basementPlease selectYesNo4. Boiler Replacement / RepairHow long have you had your current boiler?1 year2 years3 years4 years5 years or moreNo ideaIs the property made out or Brick or Store?BrickStoneOther / I don't knowConsent I agree to the privacy policy.NameThis field is for validation purposes and should be left unchanged.
