Contact Information of the person filling out form for any follow-up questions. LPM / Installer Name LPM / Installer Phone Number Email Address
Step 1: Provide Subscriber Information Subscriber's Phone Number Primary Subscriber Name Program Code
Step 2: Select Reason for Submitting Request Reason (Please Choose One) New Installation - Activating a New Subscription Cancellation - Remove all Equipment from an Existing Subscription and Deactivate Subscriber Note: Please only select cancellation once all devices have been removed from the customer's home Cancellation Reason (If Applicable) (Please Choose One) Nursing Home In Home Care Passed Away Didn't Want / Need Service Short Term Care Financial Switched to a different provider Moved Out of Service Area Senior Living Facility Other
Step 3: Provide Home Communicator Information Communicator 10-digit Serial Number Wearable Device Type (Please Choose One) 7000PHB Personal Help Button 7000AHB AutoAlert Help Button GoSafe Mobile Help Button Wearable Device 10-digit Serial Number for Primary User
Optional: Additional Subscriber Information Secondary Subscriber Name Wearable Device Type (Please Choose One) 7000PHB Personal Help Button 7000AHB AutoAlert Help Button GoSafe Mobile Help Button Wearable Device 10-digit Serial Number for Second User Additional Notes
