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 needs depending on your personal situation, so let us know how we can make it easier for you by filling in this form. The Priority Services Register (PSR) records households who may require additional help in the case of emergencies like loss of supply. This register is used to set up an advanced warning and assistance 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 outlined in this form at any time. If you decide that you would like to be registered on our PSR, we will record your name and information about your needs on our PSR, and share that information with others - including those who work on our behalf, the Distribution Network, and other energy companies so that you receive a more joined-up customer service now and in the future. You can read more about how we aim to provide equal outcomes for our vulnerable customers by visiting our Helping Vulnerable Customers policy, available on our website. We d be happy to talk to you about your options if you prefer to ring us. You can contact us on Alternatively, us on customer.service@first-utility.com or write to us at First Utility Ltd, PO Box 6363, Coventry CV3 9LR. If you have poor eyesight we can have your monthly bill read out to you free of charge. We can also arrange for you to receive your monthly electricity and/or gas bill in large print or Braille format. Please call us on to arrange either of these services. We also supply all our codes of practice on audio tape. Please call us to request a copy. Reference (internal use only) 1

2 Section A - About you and your circumstances Please fill in your details so we can locate you on our system: Title: Name: Energy Account number: Telephone: Address: Would you like to nominate someone to deal with your account on your behalf? By doing so, you authorise us to contact that individual and (if they agree) for us to then accept instructions from them on all aspects of your account until they, or you, tell us not to. Title: Name: Telephone: Address: Please tick this box if you would like your bills and other communications to be sent to the above individual who, you confirm, has agreed to receive them on your behalf. Please note that responsibility for payment of the bills will remain with you. Please indicate if any of the following circumstances apply to you or a member of your household: I am of pensionable age Someone in my household is of pensionable age I am chronically sick or have a long term medical condition Someone in my household is chronically sick or has a long term medical condition I have a disability or impairment Someone in my household has a disability or impairment I have a visual impairment Someone in my household has a visual impairment I have a hearing impairment Someone in my household has a hearing impairment Medical equipment is used at the property which relies on an electricity supply 2

3 Let us know the nature of the disability or impairment and who it affects so that we can identify the right services for you: There are other circumstances (not mentioned above) which mean that I may need further help. Please tell us about those circumstances here: If you ve ticked one or more of the above boxes, please continue to Section B. Section B Priority Services and our Priority Services Register There are a number of free services available to you which we hope will assist, and we ve listed them below. You can find full details about them on our website in our Helping Vulnerable Customers policy. You are also eligible to be added to our Priority Services Register (PSR) which records households who may require additional help in the case of emergencies like loss of supply. This register is used to set up an advanced warning and assistance 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 outlined in this form at any time. If you d like to be added to our Priority Services Register, tick here: Whether or not you d like to be added to our PSR, please choose from any of these additional services if they would support you in your particular circumstances: I would 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: I confirm that neither I, nor any other person, am able to read my meter, so I request First Utility to arrange for my meter to be read at appropriate intervals and for them to tell me what those readings are. 3

4 I confirm that I pay for my energy using a prepayment meter and I can t use my meter safely or practically. I d therefore like First Utility to take steps to provide safe and practicable access to my Prepayment meter. Please provide details of the difficulties you are experiencing with your prepayment meter: I would like First Utility to send communications to me in a more accessible format if possible. Please complete the following: I confirm that I m blind or partially sighted and I d like my bills / Statements of Account in the following way: Large Print Spoken word (CD / tape) Braille Tick here if English is not your first language, and use the space below to confirm your chosen language. We ll make a note of it so that we can enhance your service experience wherever possible. Section C Free gas safety check Part A To find out if you qualify for a free gas safety check, please answer the following questions: I receive means-tested benefit such as Tax Credits or Income-based job-seekers allowance I own my own home (I do not rent) If you ve ticked both these boxes, then you may be entitled to a free gas safety check. Please proceed to Part B to find out if you do: 4

5 Part B And either : I am of pensionable age, have a disability, or am chronically sick I live alone; or I live with others, all of whom are either of pensionable age, have a disability, are chronically sick, or under 18 years old. If you ve answered yes to the both questions in part A, and yes to the questions in part B, you are entitled to a free gas safety check each year. If you have not been able to answer yes to these questions, please proceed to Part C: Part C A child under the age of 5 lives at the property If you ve answered yes to both questions in part A and yes to the question in part C, you are entitled to a free gas safety check each year. If you qualify for a free gas safety check, please provide the following information: My last gas safety check was carried out on: Declaration I confirm that the information I have provided in this form is true to the best of my knowledge and that, where appropriate, I consent to this information being shared with our partners, including those who work on behalf of First Utility, the Distribution Networks, meter operators, other energy suppliers, and trusted charities such as the British Red Cross who may assist during incident situations to support us in safeguarding you and other household members. Print Name: Your signature: Thank you for completing our form. This information will help us to provide the right services and support for you. 5