Lifeline 7000 Series Installation/Deactivation Form

Lifeline 7000 Series Installation/ Deactivation Form

All forms received during Normal Business Hours (Mon - Fri 8:30am to 8:00pm, Sat and Sun 10:00am to 4:00pm) will be handled within four hours of receipt. Forms received out of these hours will be actioned on the next business day.

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

Note: Please only select cancellation once all devices have been removed from the customer's home

Cancellation Reason (If Applicable)

Step 3: Provide Home Communicator Information

Communicator 10-digit Serial Number

Wearable Device Type

Wearable Device 10-digit Serial Number for Primary User

Optional: Additional Subscriber Information

Secondary Subscriber Name

Wearable Device Type

Wearable Device 10-digit Serial Number for Second User

Additional Notes

Lifeline 7000 Series Installation/ Deactivation Form

Note: Please only select cancellation once all devices have been removed from the customer's home

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