Vulnerability Notification Form Telling us about your personal circumstances

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1 Vulnerability Notification Form Telling us about your personal circumstances Why give us this information? To offer you the right support, we ll need to understand your circumstances. We know that you may have different needs depending on your personal situation, so let us know how we can make it easier for you by filling in this form. We only share your personal information with those who work on our behalf and the Distribution Network, who may share with other energy companies if they need to. This is so that we can tailor our services to you. There s a full description of the eligibility criteria and available services on our website in our Helping Vulnerable Customers policy. Have a look at this before completing your form. We d be happy to talk to you about your options if you prefer to ring us. You can contact us on Section A Fill in your details so we can locate you: Title: Name: Energy Account number: Telephone: Address:

2 If any of this information applies to you tick the box: I am of pensionable age I am chronically sick, or have long term ill health I am blind or partially sighted I am deaf or have a hearing impairment I have another disability Let us know the nature of your disability so that we can identify the right services for you: If you ve ticked one or more of the above boxes, please continue to Section B. If you haven t, please skip sections B and C and proceed to Section D. Section B services and our Priority Services Register There s a number of additional free services available and we ve listed them below. You can find full details about them on our website in our Helping Vulnerable Customers policy. You re also eligible for our Priority Services Register (PSR) which records households who may need additional help in the case of emergencies like loss of supply. This register is used to set up an advanced warning and additional help if there s a planned interruption to your supply. You can ask us to remove your name from the PSR or stop any of the extra services at any time. If you d like to be added to our Priority Services Register, tick here: Whether you d like to be added to our PSR or not, choose from any of these extra services if they d support you and your circumstances: I d like to set up a password / signal to be used when a First Utility representative visits my home. My preferred password / signal is as follows:

3 Section B / I d like to use the Intermediary Nomination Scheme, where you will arrange for my bills to be sent to the following individual who, I confirm, has agreed to receive them on my behalf. I understand that responsibility for payment of the bills will remain with me: Title: Name: Telephone: Address: I confirm that no other person occupying my premises is able to read the gas or electricity meter, so I request First Utility to arrange for my meter to be read at least once every quarter. I confirm that I pay for my energy using a prepayment meter and I m unable to make payments, due to my infirmity. I d therefore like First Utility to consider moving my prepayment meter, if they can, to allow easier access. I confirm that I m blind or partially sighted and the format that I d find more accessible for my bills / Statements of Account is: Large Print Spoken word (CD / tape) Brail If you re blind or partially sighted, deaf or hearing impaired, contact us at any time for additional assistance if you need to ask or complain about any bill or statement of account you receive from us. Please proceed to Section C.

4 Section C Other Services If you ve ticked one or more of the boxes in Section A and you re a homeowner (it s not rented), complete the following information. If you re not a homeowner, go straight to Section D. I receive means tested benefit and I live alone I receive means tested benefit and live with others, all of whom are either of pensionable age, disabled, chronically sick or under 18 years If you ve ticked either of the above boxes, you may be entitled to a free gas safety check each year: I d like a free gas safety check each year. My last gas safety check was carried out on: Proceed to Section D to tell us about anything else that may be relevant. Section D Any other circumstances If you feel that your circumstances make you vulnerable in any other way, fill out the following information as there may be other services we can offer now, or at a later date: A child under the age of 5 lives in the property If you ve ticked the above box and you re a homeowner and you re on means tested benefit, you may be entitled to a free gas safety check every year: I m a homeowner, I receive means tested benefit and would therefore like a free gas safety check each year. My last gas safety check was carried out on:

5 One or more person (other than myself) living in the property is of pensionable age, disabled or chronically sick Tick the relevant box below if it applies to at least one other occupant at the property: Occupant is of pensionable age Occupant has any disability Occupant is chronically sick I am pregnant My baby is due (approximate date): I have individual needs based on other circumstances I haven t yet mentioned in this form. Tell us about this here: Thank you for completing our form. This information will help us to provide the right services and support for you.