Title Page
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Site conducted
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Installers must complete this form with the Customer and submit to the Primary Bidder as part of their monthly claim. Multiple measures can be claimed for on this form if completed by the same installer. If separate installers are used, a separate claim form must be completed
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Primary Bidder Details
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Scheme Name
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Managing Agent Details
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Installer Details
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Job Reference:
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Address Line 1
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Address Line 2
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Type of Measures being installed
Installation Details
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Address Line 1
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Address Line 2
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Address Line 3
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Postcode
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Type of Property
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Year of Build
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Number of Bedrooms
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Fuel Type Before Installation
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Fuel Type After Installation (Applicable to WHS Schemes Only)
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Boiler
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Loft Insulation installed?
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Depth of Loft Insulation installed
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Loft Insulation - Soffit Vents installed?
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Loft Insulation - Roof Vents installed?
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Full-Fill CWI installed?
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Partial Fill CWI installed?
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CWI - Extraction and fill?
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Wall Insulation Vents installed?
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Solid Wall Insulation - Internal installed?
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Solid Wall Insulation - External installed?
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Chimney Draught Excluder Installed?
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Smart "Remote-App" Heating Controls Installed
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Draught Proofing
- Yes
- No
- N/A
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Water Widget
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HWTJ
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Reflective Radiator Panels
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Number of LEDs Installed
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Customer Declaration - By signing below, I confirm that I am satisfied with all works installed and that all details provided above are true and accurate to the best of my knowledge. I confirm that I have read the Data Protection Statement below.
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Level of NISEP Funding towards measure(s) installed:
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If applicant unable to sign - state name of person signing on the applicant's behalf
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Signature of person signing on applicant's behalf
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Relationship of person signing on customer's behalf to the customer
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Guarantees: Appropriate guarantees have been applied for and provided to the customer, including but not limited to, Manufacturer's Warranty, Workmanship Warranty, MCS Certificate, Wall Insulation Guarantee Certificate
- Yes
- No
- N/A
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Installer Declaration: By signing below, I confirm that all details provided above are true and accurate to the best of my knowledge. I have completed the installation as per NISEP requirements (for heating installs, this includes the completion of a water pressure test prior to commissioning new/upgraded system).
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Signature of Installer
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Building Control & Planning Permission (if applicable): If applicable, Building Control has been applied for, appropriate fee paid, and customer has been provided with appropriate paperwork to arrange Building Control survey. Building Control has been informed of completion of works. If applicable, Planning Permission has been applied for, appropriate fee paid, and permission granted.
- Yes
- No
- N/A
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By submitting this claim the Primary Bidder is declaring that they have undertaken all NISEP requirements, including quality monitoring and, where applicable, remedials have been completed for this measure(s) and signed off by an independent quality inspector. Any false declaration made as part of this claim may constitute as evidence of fraud and will be dealt with accordingly.
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Scheme Eligibility Criteria Met and Documents Verified
- Yes
- No
- N/A
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Tenure Verified
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If Private Rented, Landlord Registration Verified and consent received?
- Yes
- No
- N/A
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Primary Bidder Signature
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Date of Primary Bidder Signature
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Data Protection Statement:
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Data is collected securely in compliance with current Data Protection Regulations. Energy Saving Trust, as Programme Administrator are required to share this information with the Utility Regulator and other grant funding providers, for payment processing, to verify the installation of measures under NISEP and to confirm that grant funding for the measure installed has not been obtained from other public programmes. In addition, information may be shared with your local council building control department, planning authority, MCS, and wall insulation guarantee providers, where applicable. These parties are subject to and comply with GDPR. Energy Saving Trust, as Programme Administrator may contact you to verify the information provided in this claim form and in some instances for customer feedback.
