Customer IDName(Required) First Last Email(Required) Phone(Required)Permission to contact you via email Send me email updates Email me with relevant service & product information Select AllPermission to contact you via phone You may call me You may send me text message updates Select AllHow can we help?(Required) Check Eligibility For No-Cost Energy Upgrades (HES-IE) Energy Audit (Home Energy Solutions) Home Insulation Window Replacement Heating & Cooling Upgrades Rebates Other Heating Cooling Select AllAdditional NotesHiddenIntake StatusNot SetLVMBills requestedIE to CORAwaiting ApprovalScheduledLOST compNot InterestedOut of StateUnsureOtherDuplicateHiddenIntake NotesHiddenIntake Assigned CORIntake-assigned COR RepUnassignedWanda SantanaColleen Ebanks-shippeyKimberly LucasGrace StewartLeslie HunterRegina AliceaDonald MosesAndrea HillBrenda GonzalezOn NomotoChristopher KellyJoanaida Acevedo MartÃnezFrances MejiasHiddenutm_campaign Hiddenutm_source Hiddenutm_term Hiddenutm_medium Hiddenutm_content Hiddengclid Hiddenfbclid Hiddenfirst_utm_campaign Hiddenft_referral Hiddenlt_referral Hiddenft_landing Hiddenlt_landing Hiddenorganic_source Hiddenorganic_source_str HiddenhandlID Hiddenhandl_ip Hiddencor_id Hiddencor_code Hiddenaffid HiddenPassthrough Sourceref2appappo2appHiddenCOR Rep NameCode-controlled value assigned based on cor rep page HiddenCOR Rep IDCode-controlled value assigned based on cor rep page HiddenReferrer Name First Last HiddenReferrer Email HiddenReferrer PhoneHiddenReferrer Address Street Address Apartment Number City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HiddenReferred Prospect ID HiddenMatch And Catch ID HiddenPDF URLPDF URL from Review & Sign. Filled Programatically. HiddenProperty Owner Authorization URL Thank you for your inquiry! A representative will be in touch soon. Want faster service? Answer a few more questions below! Previous Energy AuditHave you ever had a home energy audit before? Yes, I've had an energy audit No, I've never had an energy audit Previous Energy Audit DateApproximately when did you have your last energy audit? Month Day Year Low-Income Eligibility (optional)If your combined household income is less than 60% of the CT median income, you may be eligible for free-of-charge, Home Energy Solutions - Income Eligible services. Yes, check my income eligibility No, thank you Household Occupancy(Required)How many people live in your household?Household Income(Required)What is your total household income? (Proof of income may be required for some programs).Adults in Household(Required)How many household members are over the age of 18?HiddenIE Max 1HiddenIE Max 2HiddenIE Max 3HiddenIE Max 4HiddenIE Max 5HiddenIE Max 6HiddenIE Max 7HiddenIE Max 8HiddenID Diff 1HiddenID Diff 2HiddenID Diff 3HiddenID Diff 4HiddenID Diff 5HiddenID Diff 6HiddenID Diff 7HiddenID Diff 8 The details you provided suggest you might be pre-approved! Let's connect you with a Community Outreach Representative for a FREE in-home visit. COR Appointment DateWhat would be a good day for your Community Outreach Representative (COR) visit? (You can change this later when your representative calls you) MM slash DD slash YYYY COR Appointment Time Hours : Minutes AM PM AM/PM HiddenCOR StatusNot SetLVMText MessagedNot InterestedUsed Another VendorCOR Visit ScheduledAudit ScheduledHiddenCOR Notes Electric Company(Required)Who is your electricity provider? Eversource UI Electric Account Holder(Required)Is the electric account under your name? Yes, electric is in my name No, electric is NOT my name Electric Account Number(Required) Electric Account Holder's Name(Required) First Last Electric Bill UploadClick "Add Electric Bill" to upload a copy of your electric bill. Upload Electric Bill Actions Edit Delete There are no Electric Bills. Add Electric Bill Maximum number of electric bills reached. Heating Fuel Type(Required)How do you heat your home? Oil Heating Electricity Heating Gas Heating Propane Heating Hot Water Fuel Type(Required) Oil Electric Gas Propane Gas Company(Required)Who provides your gas? Eversource CNG SCG Gas Account Holder(Required)Is the gas account under your name? Yes, gas is in my name No, gas is NOT in my name Gas Account Number(Required) Gas Account Holder's Name(Required) First Last Gas Bill Upload Upload Gas Bill Actions Edit Delete There are no Gas Bills. Add Gas Bill Maximum number of gas bills reached. We'll start prefilling your application for you with the information you provideService Address(Required)Please provide the address for which you are requesting service Street Address Apartment Number City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Ownership(Required)Do you own or rent your home? I own my home I rent my home Type of Home(Required)What type of home do you live in? Single-Family Home Apartment Condominium Year of Home Construction(Required)What year was your home built?Home Size(Required)What is the approximate square footage of your home?Number of Units(Required)How many dwelling units are in your building?Primary Heating System Forced Hot Air Baseboard Radiator Other Primary Cooling System Central Air Window Unit Mini-split Other The options below will allow us to get you qualified. Utility Payment Programs(Required)If you participate in one of these programs, please select it below. Documentation will be required. Eversource: New Start Eversource: Matching Payment United Illuminating: Forgiveness United Illuminating: Matching Payment No Utility Payment Programs Proof of ParticipationClick "Add Document" to attach an email, letter, or screenshot of your participation in a utility payment program. Upload Proof of Participation Actions Edit Delete There are no Documents. Add Document Maximum number of documents reached. Government Assistance Programs(Required)If you participate in one of these programs, please select it below. (Documentation will be required.) EBT Award Letter for Supplement Income Recipients Energy Assistance Award Letter Section 8 Housing Choice Voucher No Government Assistance Upload government assistance award documentUpload one of these documents: EBT Award Letter for Supplement Income Recipients, Energy Assistance Award Letter, or Section 8 Housing Choice Voucher Upload government assistance award document Actions Edit Delete There are no Assistance Documents. Add Assistance Document Maximum number of assistance documents reached. Based upon your previous selections, we'll try to qualify you on an income basis. Please answer the questions below.Income Earning Adults(Required)Does any ADULT (over 18 years old) in the household earn income from ANY source (including yourself)? Yes, there are ADULT income-earners in the household No, there are no income-earning adults in the household Rental Income(Required)Are you a landlord that receives income from rental properties? Yes, I'm a landlord No, I'm not a landlord Income-Earning AdultsPlease provide the names and incomes of all income earning adults in your household. Include yourself if you earn income. Name Annual Income Proof of Income Upload Proof of Income Actions Edit Delete There are no Income-earning Adults. Add Income-Earning Adult Maximum number of income-earning adults reached. Adults with No Income(Required)Are there any ADULTS (over 18 years old) WITHOUT income living in the household? Yes, one or more adults earn no income No, all adults earn income (and have been listed above) Sum of Household IncomeThis field contains the sum of all incomes provided above. HiddenAffidavit Signer NameWe've copied this for you, only change if necessary. This name should match the applicant and the account holder. Household Members with No Income(Required)Enter the FULL names (first and last name) of EACH household members with no income. Click the + button to add new rows. IF YOU ALSO EARN NO INCOME, YOU MUST ALSO INCLUDE YOUR NAME.Full Name Add RemoveAffidavit for Household with No Income: I affirm that no adult over the age of 18 years, listed above, who lives in my household, has had any income in the four weeks prior to the date this affidavit is signed below. This means no adult in my household and is listed below has received income from employment, a pension, unemployment or worker's compensation, cash assistance from the Connecticut Department of Social Services (Temporary Family Assistance, State Supplement or the State Administered General Assistance program), benefits from the Social Security or Veteran's Administration, child support, alimony, interest, or any other income source. The following people live in my household and have no income:I understand that the HES-IE program may request supporting documentation regarding my income. I affirm that the information indicated on this form is accurate. I understand that if the information is not correct, I may be charged for the energy efficiency services I am provided by the HES-IE program.Affidavit Acknowledgement(Required) I understand and agree to these terms. No Income Affidavit Signature(Required)No Income Affidavit Signature Date(Required) MM slash DD slash YYYY This form is for applicants who also earn income as landlords/property owners.Monthly Rental IncomeEnter the amount of money you receive each month from your tenants.Address of property from which you earn income Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Rental Income SignatureRental Income Signature Date MM slash DD slash YYYY Earlier, you indicated that you rent your home. We will need to get authorization from your landlord. Please fill the section below.Landlord Name(Required) First Last Landlord Phone Number(Required)This information may be used to contact your landlord for authorization. Please notify your landlord.Landlord Email(Required)This information may be used to contact your landlord for authorization. Please notify your landlord. Landlord Authorization Request(Required)We will send your landlord an email to sign the authorization online with the subject line "Home Energy Solutions Landlord Authorization Request". Please make sure to contact your landlord to let them know to sign this authorization. I have contacted my landlord. Please send my landlord an email to sign the authorization. Your landlord will be emailed once you've completed all the required fields and submitted this form. Your application will not be complete until your landlord provides authorization.HiddenProperty Owner Authorization Entry IDNameThis field is for validation purposes and should be left unchanged.