Application form

Fill in the application form below to apply for free or discounted insulation.

I am:

Select all applicable:

In receipt of an income related benefit

Not receiving any of the benefits listed above but have an annual household income of less than £18,000 before tax

Have an annual household income of more than £18,000 before tax

Your Home:

I am a:
My main form of heating is:
I live in a:
Which is:
No. of bedrooms:
Year property was built (approx):
I am interested in free or discounted:

Cavity wall insulation
Loft insulation

Your Contact Details:

Name:
Address:
Postcode:
Which local authority area do you live in?
Telephone no:
Mobile no:
E-mail address:

If You Have One, Please Enter:

Campaign code:
Referral code:

Finally:

Where did you hear about Cosy Devon?:

Tick if you would like to have a Home Safety Check carried out by the Devon & Somerset Fire and Rescue Service

Tick if you would like to receive advice on whether you are eligible to receive any benefits (or increase your benefit entitlements)

I give permission for this information to be used by Cosy Devon (managed by Energy Action Devon) and shared with their partners for the purpose of improving the energy efficiency of my home and, if requested, helping me to access benefits, safety and welfare advice. The information will not be given to other agencies and will be held in accordance with the Data Protection Act 1998.