ECO Form (Internal)Complete the form below...Please enable JavaScript in your browser to complete this form.Energy Advisor name *Property Tenure *HomeownerPrivate rentedSocial rentedCustomer detailsCustomer name *FirstLastCustomer address *Customer town *Customer postcode *Customer telephone *Customer email *Customer date of birth (dd/mm/yy) *Rural (Check Ofgem Site) *YesNoClick the link to check if a postcode is in an eligible HHCRO Rural area - Rural Postcode search- Zero Waste Scotland Landlords Details (if Required - PRS)Landlords *FirstLastTelephone Number *Email Address *HHCRODoes anyone in your household receive a state benefit? Select all that apply. *No benefitsUniversal CreditIncome based Job seekers allowanceIncome related employment & support allowanceIncome SupportHousing BenefitTax Credits (Child or Working Tax Credit)Child BenefitPension Credit Guarantee Credit Pensions Credit Savings Credit Eco4 Child Benefit income thresholds (before tax & N.I)Single claimant -1 child £19,900Single claimant -2 children £24,800Single claimant -3 children £29,600Single claimant -4 children £34,500Member of a couple - 1 child, £27,500Member of a couple - 2 children, £32,300Member of a couple - 3 children, £37,200Member of a couple - 4 children, £42,000Eco Flex RouteLocal Authority AreaNorth Lanarkshire CouncilSouth Lanarkshire CouncilAngus CouncilDundee City Aberdeen City Perth & Kinross South Ayrshire CouncilNorth Ayrshire CouncilEast Ayrshire CouncilRenfrewshire CouncilDumfries & GallowayRoute 1: Household Income - Gross annual income less than £31,000YesNoRoute 2 (Must select 2 of the following. 1&3 and proxies 6&7 cannot be used in combination with each other)1.Homes in England in Lower-layer Super Output Area (LSOA)1-3 on the English Indices of Deprivation 2019 or homes in Wales in LSOA 1-3 on the Welsh Index of Multiple Deprivation 20199 , or homes in Scotland in “data zone” 1-3 on the Scottish Index of Multiple Deprivation 20202.A person living at the premises receives a Council Tax reduction on the grounds of low income.3.A person living at the premises is considered to be vulnerable to the cold under the National Institute for Health and Care Excellence (NICE) Guidance: Recommendation 2, for a reason other than their low income.4.A child living at the premises is eligible for free school meals, due to low-income5.A person living at the premises is supported by a LA run scheme that is named and described in their Statement of Intent, and established to support people living on a low income and vulnerable to the cold under NICE Guideline NG6,6.A person living at the premises has been referred to the LA for support by their energy supplier, Citizens Advice or Citizen’s Advice Scotland because they have been identified by the referrer as struggling to pay their gas or electricity bills7.The household has been Identified through supplier debt data to Identify either Non Pre-payment meter households ( non-PPM), or Pre-payment meter households(PPM)Are any of the household occupants vulnerable to living in a cold home due to any of the below circumstances?People with cardiovascular conditionsYesNoPeople with respiratory conditions (in particular, chronic obstructive pulmonary disease and childhood asthma)YesNoPeople with mental health conditionsYesNoPeople with disabilitiesYesNoOlder people (65 and older)YesNoHouseholds with young children (from new born to school age)YesNoPregnant womenYesNo(Evidence: require signed letter from Doctor / GP indicating the householder is vulnerable to living in a cold home due to one of the above circumstances)Do any of the householders receive free school meals due to low income?YesNo(Evidence: require letter indicating eligibility for free school meals based on low income provided by the school or LA)Are any of the householders supported by a Local Authority Scheme that assists low income and vulnerable households? E.g. HEATYesNo(Evidence: Require signed letter from LA / local co-ordinator that proves the householder was eligible for the LA run scheme)Has the household been referred to the Local Authority for support by their energy supplier or Citizen’s Advice Scotland, because they have been identified as struggling to pay their electricity and gas bills.YesNo(Evidence: signed letter accompanied by proof of electricity and gas debt from the energy supplier or Citizens advice showing that the household has been referred to the LA for utility bill support)Non-PPM Customers: Customers who have been in debt for more than 13 weeks ending with the day on which the declaration is made, and are in a debt repayment plan with their energy supplier or repaying their fuel debt through 3rd party deductionsYesNoPPM Customers: Suppliers may also identify PPM households who: • Have either self-disconnected or received supplier discretionary/Friendly credit within the last 13 weeks ending with the day on which the declaration is made; or • Are in a debt repayment plan with their energy supplier; or • Repaying their fuel debt through 3rd party deductions YesNoRoute 3:NHS Referrals (Identified as housing a person suffering from a severe and / or long-term health condition that is adversely affected by living in a cold home ). The person’s severe or long term health condition must be due to :A cardiovascular conditionA respiratory diseaseLimited mobilityImmunosuppressionThe LA must complete a declaration certifying that it has received a referral from one of the following: • A General Practitioner (GP) • A Scottish Heath Board • A Welsh Health Board • An NHS foundation trust • An NHS TrustIs this job progressing further? *YESNO No – Unfortunately, from the information provided you do not qualify to access the eco grant funding however, there is financial support available for insulation, solar and renewable technologies from Home Energy Scotland, alternatively we can provide you with a quotation for any measures you’re interested in.Would you like a quotation for the works? *YESNO Thank you for your enquiry, A member of our sales team will contact you within 24hours to discuss the measures you’re interested in and provide you with a quotationWhat is your main heating type? *Mains Gas Oil LPG Electric BoilerStorage HeatersElectric Room HeatersMultifuelOtherIs your boiler condensing or non condensing? Does it have a white plastic pipe coming from below the boiler? *Condensing - Yes white plastic pipeNon-Condensing - No white plastic pipeDon't knowNot Applicable You can find your boiler type using the Product Characteristics Database (PCDB) by Clicking HereUnderfloor Heating *YesNoRads *YesNoHeating Controls *NoneThermostatProgrammerTRVsZonalSecondary Heating:Water HeatingHot Water Tank YesNoCylinder Size Insulation Foam Jacket Additional Info: (Dimensions, Conservatory, Renewables etc)What is the current EPC band for the property? Check post code and address on the Scottish EPC register *EFGNo EPC Home (scottishepcregister.org.uk)What is the total floor area of the property? Check EPC data *0-7273-9798-199200+No EPCIs this job progressing further? *YESNO Unfortunately, from the information provided you do not qualify to access the eco grant funding however, there is financial support available for insulation, solar and renewable technologies, alternatively we can provide you with a quotation for any measures you're interested in.Would you like a quotation for the work?YesNoProperty TypeHouseBungalowFlatDetachedSemi DetachedMid TerracedEnd TerracedNumber Of Storeys 123Habitable Rooms Heated Habitable Rooms When was your house built? (if unknown approximate) *Pre-19191919-19291930-19491950-19641965-19751976-19831984-19911992-19981999-20022003-20072008-20112012+Extensions Pre-19191919-19291930-19491950-19641965-19751976-19831984-19911992-19981999-20022003-20072008-20112012+NoneRoom-in- RoofPre-19191919-19291930-19491950-19641965-19751976-19831984-19911992-19981999-20022003-20072008-20112012+NoneWallsWhat is your wall construction type?GraniteSandstoneSolid BrickCavityTimber Frame Concrete Wall InsulationYesNo RoofsRoofs PitchedFlatJoist or Room in RoofJoistRoom in RoofBothNoneRoof Insulation YesNoInsulation Thickness Floors Floors SolidTimberFloor InsulationYesNoAdditional informationGlazing TypeSingleDouble < 2003Double > 2003Double Unknown DatePVCNon-PVC6mm12mm16mmOpen Fireplaces Total Number of Light FittingsTotal Number of LELsQualifying Measures ( Select all that apply) *Air source heat pumpInternal wall insulationUnder-floor insulationHHR storage heatersCavity wall insulationSolar PVGas boilerRoom in roof insulationLoft insulationFTCHFlat Roof InsulationPlease write any other important information here How did you hear about us? *FlyerRecommendationInternet search engine (eg. Google)TVRadioSocial media (eg. Facebook)Referral RewardShelter ScotlandOther£100 Referral Reward - if you were referred to us by a friend or family please tell us their nameIf you are referred to us by a friend or family we will pay them a Referral Reward of £100 cash upon completion of your energy efficiency measure installation. For the claim to be valid you must include the referrer name here at time of initial enquiry.£100 Referral Reward - referrer contact detailsPlease tell us the referrers contact telephone number or email addressPrivacy policyWe will never share your details with third parties without your permission. By submitting this application you consent to the processing of your personal data in accordance with our Privacy Policy which can viewed online at: www.greenhomesystems.co.uk/privacy-policy *I agree with the Privacy PolicyClosing scriptWe will now continue to process your ECO energy efficiency grant, and will contact you again soon by telephone so please look out for a call from us on 01294 208 300. We will send you an email to confirm all of this and if you would like to contact us before then please reply directly to the email or phone us on the number provided.As a thank you for contacting us we are offering you the chance to claim a £100 Referral Reward. If you refer another customer to us who is eligible for an ECO energy efficiency grant then we will reward you with £100 cash. Remember that there is no limit to the number of Referral Rewards you can claim, so please let all your friends and family know. We will email the details of this to you shortly. My name is [NAME] , and I hope you continue to have a great day.Although we are not able to progress your application today, as a thank you for contacting us we are offering you the chance to claim a £100 Referral Reward. If you refer another customer to us who is eligible for an ECO energy efficiency grant then we will reward you with £100 cash. Remember that there is no limit to the number of Referral Rewards you can claim, so please let all your friends and family know. We will email the details of this to you shortly. My name is [NAME] , and I hope you continue to have a great day.Submit
