Self declaration form - Watersure | Get in touch

Self declaration form - Watersure

Letting us know you’re still eligible for the scheme, you’re saying that your circumstances haven’t changed and you’ll continue to benefit from capped water bills.

If you let us know you're no longer eligible for the scheme future bills will be based on the amount of water you use. If we don’t receive the ‘self declaration form’ back, we’ll assume you are no longer eligible & remove you from the scheme, a new application will have to be submitted to get back onto the scheme.

About you

Account number: *

Please enter a valid value

Full name: *

Please enter a valid value

Email *

Please enter a valid value

Benefit

Are you in receipt of any of the following benefits? If yes please tick all that apply

Please select an option

If you answered no to the above: Are you in receipt of DLA or PIP? If yes, please tick the box that applies

Please select an option

Medical

As your WaterSure application includes information about your medical condition, we need your consent to process your application. I consent to my medical information being processed

Please select an option

Do you have a medical condition which requires the use of additional water? *

Please select an option

Family

Tick this box if there are 3 or more children in the household under 19 years of age

Please agree to our terms and conditions

I confirm that my circumstances haven’t changed and I am still eligible for the WaterSure scheme. I agree that I will provide proof I still qualify for the scheme if asked. If I cannot provide this I will be taken off the scheme and I will receive a bill *

Please agree to our terms and conditions

When a customer applies for Watersure we promote our Priority Services Register. If you are already enrolled onto our priority service register, please confirm if you still require the service - if so, please sign below to confirm you are still eligible.If you aren’t already registered and you would like to enrol we need your consent that you are happy for us to hold and use your data to provide you with additional support. This means if you have a child in the property 2 years old or under or someone with a medical condition with the need to use more water, if there is a supply issue we can identify and give you extra support. Registered customers will receive prior notification of planned work, priority notification in case of any emergency and an alternative water supply where needed.

Priority Services Register

Please agree to our terms and conditions

If you would like to enrol onto the Priority Services Register please complete the below.

Please tick if any of the following apply to someone living in your property:

Please select an option

Details about medical condition/requirement

Please enter your description

Is an alternative water supply required?

Please select an option

Please tick the box if: *

Please select an option

Please tick the box if:

Please select an option

Please check you have completed all the sections that are true and reflect your circumstances before you submit the form.

Internal form number: WS001