Check your Eligibility Not want to complete the full form? Check out the quick form on our contact page. Quick Form Check your Eligibility In order to process your application, please provide the following information Your DetailsName* First Last Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* When is best to contact you?MorningAfternoonEveningOr by email1. Your HomeTo find out if you qualify for a FREE central heating boiler under the Government's Affordable Warmth Scheme, please tick the relevant box below which applies:Are you*A home owner (you own your home outright or you have a mortgage)A tenant in a privately owned property2. Your BenefitsThere are four ways you can qualify under the Affordable Warmth Scheme Benefit Test, but you only need to pass one of them. Please tick all of the relevant boxes below which relate to your state benefits.Please note that Pension Credit is a means-tested benefit and is paid in addition to a state pension for those who qualify. Please only tick this option if you receive Child Tax Credit and your household income is less than £15,860. Child Tax Credit is related to your income and is different to Child Benefit. Please select any benefits received within the home* Pension Credit Child Tax Credit Income Support (IS) Working Tax Credit (relevant income below £16,010) Income based Job Seeker's Allowance (JSA) Income related Employment & Support Allowance (ESA) Are there any children in the property?*No childrenChild under 16Child under 18 in full time education (excludes University)Please select any other benefits received: Disabled Child Premium Pension Premium Disability Premium Employment Support Allowance (work related activity) Please select any options that apply: Aged 60 or over Receive disabled worker element Receive severe disability element This information will only be used to determine your eligibility to qualify as part of the Affordable Warmth Scheme and you will be asked to provide evidence of any benefits you receive, at the time of the technical survey. 3. The Energy Efficiency of Your Central Heating BoilerDomestic central heating boilers are rated from 'A' (very efficient) to 'G' (very inefficient) and we need to know the make and model of your boiler to see if it will qualify.IMPORTANT: If any of the following information cannot be easily obtained from the outside casing of your boiler or from any documentation you may have, please DO NOT attempt to dismantle any part of your central heating system to obtain it. Simply tick the "Don't Know" box below and leave it to the Technical Surveyor.What type of fuel does your main heating system use?*GasOilElectricityLPGCoalBoiler make? if knownAfosAga RayburnAladdin IndustriesAndrewsBarloBaxi HeatingBoulterBurco MaxolCaradon IdealCastlereagh Boiler ServicesChaffoteauxCharles Portway & SonClaudio GR (Vokera)DelheatELM LeblancFerroliGledhillGlow-wormHalsteadHarford-UnicalHartionexHenry WilsonHepworth HeatingHusqvarnaIMI WaterheatingIntertherm IncLivinLuxuryMacFarlane Bros (Heat)MaxolMTSMysonNewflameOceanspaOerlikon Welding (Unidare)ParkrayPerrymaticsPottertonPotterton International HeatingPotterton MysonPotterton Myson HeatingPowermaticPyrocraftR H IngramRadiantRadiationRobinson WilleySaunier DuvalServowarmSime Heating Products (UK)SinclairSmith and WellstoodSolarcombiStewart Automatic BoilersSupermatic InternationalThorn EMI HeatingTriancoVaillantViessmannVokeraWickesWorcesterOtherI'm not sureBoiler Model No. if known4. The Nature of the Fault with Your Central Heating BoilerThe Technical Surveyor will assess any fault with your existing central heating boiler but to help us, please tick the boxes below which you think may apply: Is your boiler a condensing boiler? Does your boiler have a square flue? Have you got a boiler behind your gas fire? Has your property had a new boiler fitted in the last 10 years? Does your boiler have a permanent pilot light even when not operating? Don't know. If other (please describe the fault)The condition of your central heating boiler or other faults with it may mean that you still qualify but the Technical Surveyor will carry out an assessment to determine this.Please tick the following boxes to indicate which energy efficient products you would be interested in: Cavity wall insulation Loft insulation Roof insulation Flat roof insulation Double glazing Under floor heating Energy efficient and water efficient showers Solar pv CommentsThis field is for validation purposes and should be left unchanged.