JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Do you qualify to get money back for your old boiler? Find out now.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Customers name
*
Your answer
Customers number
*
Your answer
Are you a homeowner?
*
Yes
No
How old is the boiler you're currently using?
*
Less than 5 years
5-10 years
10-15 years
15-20 years
20+ years
Don't know?
What fuel does it use
*
Gas
LPG
Oil
What kind of boiler do you have?
*
Combi
Heat only
System
How would you describe your boiler?
*
Not working
Old
Not your ideal boiler
Not energy efficient
Other:
Does your boiler have any of these problems?
*
Leaking or dripping
Operates with a loud noise
Keeps dropping pressure
Pilot light keeps going off
No heating/hot water
Cold radiators
Boiler won't respond to thermostat
Where is the boiler mounted?
*
Floor
Wall
Where is the boiler located?
*
Living room
Kitchen
Bedroom
Utility Room
Loft or Attic
Airing cupboard
Garage
If you want to move the boiler, where would you move it to?
I'd keep it in the same place
Same room
Living room
Kitchen
Bedroom
Utility room
Loft or Attic
Airing cupboard
Garage
Clear selection
How many bedrooms do you have?
*
1
2
3
4
5
6
7+
How many bathtubs do you have?
*
1
2
3
4
5+
How many showers do you have?
*
1
2
3
4
5+
How many radiators do you have
*
0-5+
6-9+
9-12+
12-15+
15-18+
18+
Where does your flu come out?
*
Roof
Wall
Submit
Clear form
Never submit passwords through Google Forms.
Forms
This content is neither created nor endorsed by Google.
Report Abuse
Terms of Service
Privacy Policy
Help and feedback
Contact form owner
Help Forms improve
Report