Home Heating Scheme Membership - Landlords Sign up now! " Don’t worry if you don’t have time to complete this entire form now – please scroll to the bottom of this form and click on the “Save and Continue Later” link. HOME HEATING SCHEME MEMBERSHIP - LANDLORDS Your DetailsFull Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Surname Email* Home PhoneMobile NumberPermanent Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Address of property to be covered (if different from above) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Additional properties (including post code):Extra Property details You can add up to 4 additional properties that you would like to coverCompany Name (if Applicable)Join ApplicantIf joint membership, please add other customer name:Full Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Surname Your Cover InformationWhat date of the month would you like to make your payment?*1st15thMonth and year you would like to start the cover (Month/Year)*MonthYear Scheme Type (inc free boiler service)*Standard £ 13.00Premier £ 20.00Deluxe £ 28.00The above fees are charged monthly.Option Back boiler £5.00 monthly Gas Fire £5.00 monthly Gas Cooker £5.00 monthly Gas cooker/hob £5.00 Shower Pump £5.00 monthly Tenanted property £5.00 monthly Optional extras - Any other requests must be agreed prior to agreement.Your Boiler DetailsYour boiler make and modelAge of your boilerWhen was your boiler last serviced?within 1-2 yearswithin 2-3 yearsMore than 3 years agoHas there been a system flush?*YesNoIf Yes what was the date - and any other comments?Is there any pre existing faults?*YesNoAny pre existing faults - please give details:Landlords only – Tenant informationThis allows us to make direct contact with the Tenant in an emergency, when the Landlord is unavailable.Tenants Name: Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Tenants Contact Number:Tenants email address: AcknowledgementPlease ensure you have read and understand the Terms and Conditions of the scheme before you proceed. Please allow up to 14 days to register your membership. I/We agree to the Terms and Conditions of the Home Heating scheme and understand that any ‘parts’ will be chargeable only ‘up to’ a maximum charge of £99.00 (labour, emergency call outs and boiler service will be free) and any pre existing faults will not be covered. I agree* By ticking this box you agree to the terms above. Digital Signature:Printing your First Name + Middle Initial + Last Name will act as your digital signature.Date Date Format: MM slash DD slash YYYY Enter your email address Please enter your email address and we will send you a copy of this form.CAPTCHAPlease check the box to validate this form.NameThis field is for validation purposes and should be left unchanged.
