WaterSure Application - Medical condition | Get in touch

Bill Cap scheme - WaterSure application

Complete this application if you are applying for someone with a medical condition

{panel-id} Tell us about the person named on the water bill

The asterisk (*) symbol denotes required fields.

Account number:

Please enter a valid account number:

Title: *

Please enter a valid title:

First name: *

Please enter a valid first name:

Last name: *

Please enter a valid last name:

Postcode *

Please enter a valid postcode

Telephone number: *

Please enter a valid telephone number:

Email address: *

Please enter a valid email address:

Confirm Severn Trent provide the water services at this property *

Please agree to our terms and conditions

{panel-id} Medical conditions

The asterisk (*) symbol denotes required fields.

Name of person applying (if different from above)

Please enter a valid name of person applying (if different from above)

Please tell us the name of the medical condition(s) (If you receive Dialysis at hospital, this does not qualify you for WaterSure).

Please enter your description

Please tell us how this affects your water usage

Please enter your description

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

Please agree to our terms and conditions

Confirmation of the medical condition that requires the use of more water must be supported by one of the following:

Attach documents *

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Attach documents

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Attach documents

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Attach documents

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I confirm the above section has been completed by the person with the medical condition

Please agree to our terms and conditions

We need this for data protection purposes to check you're/they’re happy for us to use your/their information to enroll you/them on the scheme.

Priority Services

Following your application for WaterSure, If you have a child under two years old we would like to offer you another free service, our Priority Services Register.

To enrol on the Priority Services Register 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 there is a supply issue, we can identify you 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.

Yes, I would like to enrol on the Priority Service Register

Please agree to our terms and conditions

We will only request health data where we believe we can help to manage your account or provide additional support during an incident,should one occur.

This data will be processed under the lawful basis of Public Interest for personal data, and Substantial PublicInterest (SPI) for health data. We will keep any data you provide safe and secure.This data will be processed under the lawful basis to perform public functions in the Public Interest for personal data. The data youprovide will be reviewed at least every 2 years. For more information you can review our customer promise on our website.

By registering on our Priority Service Register you are confirming that you have a need for support either during an incident or to helpyou manage your account. If your data or circumstances change, please contact us any time to provide an update.By registering with us,you will also be automatically added to the Priority Service Register of your energy network operator and supplier. The data we sharewill only be used to provide you with their Priority Services.

Attach documents

Select File Please upload a file

{panel-id} Payment plan

The asterisk (*) symbol denotes required fields.

If you have a payment plan on your account, we’ll let you know in writing how this changes once you’re on WaterSure. It is important to note that if you do not select a payment option, we will automatically set up a monthly watercard plan on your account and details will be issued to you.

The way you pay (whether that’s direct debit or watercard) will stay the same. If you’ve got arrears on your account, your payment plan will include an amount towards the arrears.

If you don’t have a payment plan, or want to change the method of payment, please specify your preferred payment plan option below.

Direct Debit

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Watercard

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Paying for your water charges directly from your benefits

If you’re in receipt of any of the following benefits, and have arrears of more than £50 on your account, you may be eligible to have your water charges paid directly from your benefits.

Income support
Job seekers allowance
Employment Support Allowance
Pension Credit
Universal Credit - the amount of arrears needed to qualify may differ, dependant on your circumstances.

We just need your full name and National Insurance Number.

If you’re successful, you’ll pay your current charges and a fixed amount towards your arrears.

If you don’t choose a payment option, we’ll set up a monthly watercard payment plan for you.

Please confirm you would like to sign up pay your water charges directly from your benefits:

Please agree to our terms and conditions

Your full name:

Please enter a valid your full name:

National Insurance Number:

Please enter a valid national insurance number:

{panel-id} Declaration

The asterisk (*) symbol denotes required fields.

The information I’ve given is correct to the best of my knowledge and I understand that if I provide any information which is false, you may decline my application.

I will tell you if my circumstances change in any way that would affect my WaterSure eligibility e.g. change in benefits.

I give you my permission to contact third parties to confirm the information I’ve given is correct.

If I pay my sewerage charges to a different company, I give you permission to pass on the details I’ve provided so you can also consider my sewerage charges under the WaterSure scheme.

I give you permission to update my record to show me as a priority water customer which will give me assistance in the event of an interruption to my water supply.

I confirm the following:

A member of my household meets the conditions for help under the WaterSure scheme.
I only use a hosepipe or watering can to water my garden.
My household does not have an auto-filling swimming pool or pond which holds over 10,000 litres of water.
I do not receive any help towards the cost of water from the health authority.
I am not aware of any leaks at the property.
The property is not used for any commercial purposes.

I give my permission for the person in receipt of benefits to be added to the account, if not already named, in order to benefit from the WaterSure scheme.

I confirm I have read and agree with the above statement *

Please agree to our terms and conditions

Please tick the box if you consent to your details being held and used by Severn Trent Water Ltd. *

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Please tick the box if you DO NOT wish to hear about products and services we offer by post/telephone/email.

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