Lead Entry Form
*
Applicants Full Name
Business Name
*
Email Address
*
City/Town
*
Post Code
*
Address Number - Street
*
Phone
Regional Area Office
*
Interested Products
Solar Panels
Battery Storage
ASHP
ECO4
EV Charger
Boiller Upgrade
Insulation
Other
Any other details?
Project Manager
*
Lead Generator
*
Lead Gen Source
Below are details for any grant leads only
Upload to Dropbox all Images and Docs - Title the upload folder as Name and Postcode
Any Previous Grants
Yes
No
If Y - What Grant and date
EPC Expired
Yes
No
Dont know
EPC Rating
D
E
F
G
C
EPC Date
Property Ownership
Social Tenant
Private Tenant
Owner/Occupier
Full Name of person on benefits
DOB of Person on benefits
Tick any of the below benefits for the applicant
What Benefits
1) Income based Jobseekers Allowance (JSA)
2) Income related Employment and Support Allowance (ESA)
3) Income Support (IS)
4) Pension Credit Guarantee Credit (PCGC)
5) Working Tax Credit (WTC)
6) Child Tax Credit (CTC)
7) Universal Credit (UC)
8) Housing Benefit
9) Pension Credit Savings Credit (PCSC)
10) Child Benefit
(within the income caps
see Chapter 5 of the ECO4 Guidance: Delivery)
Tick all that apply to the property:
Heating
Gas boiler more than 3 years old
Gas Boiler condensing
Gas Boiler non-CondensingBoiler with BackBolierOil
Solid Fuel
Electric Storage Radiators
Other
Insulation
None
Cavity Wall Insulation
External Wall Insulation
Floor Insulation
Roof Insulation
Other Benefits Not Listed Above
Submit