Ridgewater Energy Referral Form

• Date:

  Date

• Assessor Name:

• Property Address:
  Address

• Resident/Tenant Name:

• Resident/Tenant Phone Number:

• Resident/Tenant E-Mail Address:

• Property Tenure: (private rental / owner occupier)

  Private Rental

  Owner Occupier

• Landlords Name:

• Landlords Address:

• Landlords Phone number:

• Landlords E-mail address:

Property Type

• Property Type:

  Select Detached House Semi-Detached House Mid-Terrace House End-Terrace House Detached Bungalow Semi-Detached Bungalow Mid-Terrace Bungalow End-Terrace Bungalow Ground Floor Flat Mid Floor Flat Top Floor Flat Maisonette Park Home

  • Detached House
  • Semi-Detached House
  • Mid-Terrace House
  • End-Terrace House
  • Detached Bungalow
  • Semi-Detached Bungalow
  • Mid-Terrace Bungalow
  • End-Terrace Bungalow
  • Ground Floor Flat
  • Mid Floor Flat
  • Top Floor Flat
  • Maisonette
  • Park Home

• Number of Bedrooms:

• Building Age:

  Select Before 1900 1900-1929 1930-1949 1950-1966 1967-1975 1976-1982 1983-1990 1991-1995 1996-2002 2003-2006 2007-2011 2012-2022 2023-Onwards

  • Before 1900
  • 1900-1929
  • 1930-1949
  • 1950-1966
  • 1967-1975
  • 1976-1982
  • 1983-1990
  • 1991-1995
  • 1996-2002
  • 2003-2006
  • 2007-2011
  • 2012-2022
  • 2023-Onwards

• Does the property have any Extensions

  Yes

  No

• Number Of Extensions

• Build Age of Extensions

  Select Before 1900 1900-1929 1930-1949 1950-1966 1967-1975 1976-1982 1983-1990 1991-1995 1996-2002 2003-2006 2007-2011 2012-2022 2023-Onwards

  • Before 1900
  • 1900-1929
  • 1930-1949
  • 1950-1966
  • 1967-1975
  • 1976-1982
  • 1983-1990
  • 1991-1995
  • 1996-2002
  • 2003-2006
  • 2007-2011
  • 2012-2022
  • 2023-Onwards

Does The Resident meet any of the following Criteria?

• Over 65 years of age

  Yes

  No

• Child under 5 living in the property

  Yes

  No

• Health Condition (cardiovascular, respiratory, auto-immune, mental health)

  Yes

  No

• State Which

  Select Cardiovascular Respiratory Auto-Immune Mental Health

  • Cardiovascular
  • Respiratory
  • Auto-Immune
  • Mental Health

• Anyone receiving an income related benefit

  Yes

  No

• State Which

  Select Universal Credit Employment Support Allowance Jobseekers Allowance Income Support Working Tax Credit Pension Credit (Guarantee Credit) Pension Credit (Savings Credit) Child Tax Credit

  • Universal Credit
  • Employment Support Allowance
  • Jobseekers Allowance
  • Income Support
  • Working Tax Credit
  • Pension Credit (Guarantee Credit)
  • Pension Credit (Savings Credit)
  • Child Tax Credit

• Is anyone in the household disabled?

  Yes

  No

• Anyone receiving a Disability related benefit

  Yes

  No

• State Which

  Select Attendance Allowance Disability Living Allowance Armed Forces Independence Payment Carers Allowance Industrial Injuries Disablement benefit Personal Independence Payment Severe Disablement Allowance Mobility Supplement

  • Attendance Allowance
  • Disability Living Allowance
  • Armed Forces Independence Payment
  • Carers Allowance
  • Industrial Injuries Disablement benefit
  • Personal Independence Payment
  • Severe Disablement Allowance
  • Mobility Supplement

• Household income less than £31,000 per year

  Yes

  No

• Resident had a recent trip or fall?

  Yes

  No

• Resident is a recent immigrant or asylum seeker

  Yes

  No

• Anyone in the household in the armed forces or has been in the armed forces?

  Yes

  No

• Is the Resident Pregnant?

  Yes

  No

• Has there been a recent bereavement in the family?

  Yes

  No

• Does The resident qualify for would like a Free energy advice home visit?

  Yes

  No

What measures/referral does the property require?

• Loft Insulation (150mm or less existing insulation)

  Yes

  No

• Cavity Wall Insulation

  Yes

  No

• Cavity Wall insulation (extension only)

  Yes

  No

• Room in Roof insulation

  Yes

  No

• Flat Roof Insulation

  Yes

  No

• Underfloor Insulation

  Yes

  No

• Storage Heater Upgrade (HHR)

  Yes

  No

• Air Source Heat Pump

  Yes

  No

• Solar PV

  Yes

  No

• LEAP Home Visit

  Yes

  No

• Other Home Visit

  Yes

  No

Heating Type

• What heating System does the building have?

  Select Gas Central Heating LPG Central Heating Oil Central Heating Electric Heating Air Source Heat Pump / Air Conditioner

  • Gas Central Heating
  • LPG Central Heating
  • Oil Central Heating
  • Electric Heating
  • Air Source Heat Pump / Air Conditioner

• Boiler type is

  Combi Boiler

  System Boiler

• Boiler Type

  Combi Boiler

  System Boiler

• Boiler Type:

  Combi Boiler

  System Boiler

• Electric heating Type:

  HHR Storage Heaters

  Panel Heaters

  Infrared Heaters

  Storage Heaters

• Heating Emitter

  Select With Radiators With Air Circulators/Fan heaters

  • With Radiators
  • With Air Circulators/Fan heaters

• Extra notes regarding Heating system

Cavity Wall Insulation Information:

• Does The property require Cavity Wall Insulation

  Yes

  No

• If Yes, Does the Landlord give permission for this measure?

  Yes

  No

  N/A

• Are there other Flats/Units in the building that will need the need the walls insulations.

  Yes

  No

• Number of Flats/Units

• Are there any building condition issues?

  Select No Issues Seen Poor Pointing Cracked Render Spalled Bricks Weeds in Guttering No DPC

  • No Issues Seen
  • Poor Pointing
  • Cracked Render
  • Spalled Bricks
  • Weeds in Guttering
  • No DPC

• Please take Photo of each elevation of property

  Media

• Are there any obstructions around the property

  Select No Obstructions Seen Conservatory Porch Lean-To Neighbours house in very close proximity

  • No Obstructions Seen
  • Conservatory
  • Porch
  • Lean-To
  • Neighbours house in very close proximity

Loft Insulation Information:

• Are there any Loft Areas

  Yes

  No

• If Yes, are these insulated above or below 150mm (Please ensure this is measured in at least 2 separate places and not around the hatch area)

  >Above 150mm

• How thick is the average existing loft insulation depth

  0-25mm

  26-100mm

  101-150mm

• What is square meter area of the loft that requires insulation (minimum 30m2)

• Is the height of the Loft at its Pitch. (minimum 1.2m)

• Please take photo of the loft access hatches

  Media

• Please take photo of any stored items in the loft

  Media

• ASSESSOR SIGNATURE - The information provided in this document is based on my own honest and true reflection. It has been compiled carefully to ensure accuracy and reliability. Please note that individual experiences and interpretations may vary.

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• CUSTOMER SIGNATURE - I confirm that i am happy for Bournemouth Energy to pass my information over to Ridgewater Energy to arrange the relevant assessments needed to complete this referral.

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