Home Energy Assessment and Application Form
To apply for free loft and cavity wall insulation, simply complete the form below and click send. Fields marked * are mandatory. Please rollover the info icon for additional information.

Contact Information
Title: *
Name: *

House No: *
House Name:
Street: *
Area:
Postcode: *
Age of any household persons: *
Telephone: *
info
Email:

If you are a private tenant, please complete. info
Landlord Name:
Landlord Address:
Landlord Tel:

Property Information
House Type: *
Detachment: *
Bedrooms: *
Year Built: *
Windows:
Frames:
Roof Type: *
Loft Insulation: *
Wall Type: *
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Wall Insulation: *
Cooking Fuel: *
Light Bulbs:

Central Heating Information
Boiler/System: *
Heating Fuel: *
Water Heating: *
Cylinder:
Cylinder Insul:
Controls: *
No Controls
Programmer
Room Thermostat
Radiator Valves
Appliance Thermostat

Free Advice
Free fire safety advice and smoke detector:
Free impartial and confidential benefits advice:
Free over 60's energy advice (Stoke only):
Free home security advice (Newcastle Only):

Additional Information
The following is not required, but may be used as criteria for future energy saving schemes we introduce.

How many persons in your home are currently...
Working over 20 hrs:
Retired:
Working under 20 hrs:
Unemployed:
In full time education
Not working - ill:
Full time carer:
Pre school child:
Benefits:
Income:
£ per
Ethnicity:
info
Please tick to confirm that you authorise North Staffordshire Warm Zone to process your information: *
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