Order AE-107 Annual Plan from AlertUSA

The Annual AE-107 plan is for home phones that use Standard Telephone Service or DSL (Digital Subscriber Line) Service.
Note: For DSL connections, there is a one-time $25 fee for a special line filter.

Subscriber Information
IMPORTANT INFORMATION (If you read nothing else, at least read this section): The "Subscriber" is the individual who will be using the AlertUSA service. "You" or "Your" refers to the person filling out this form. If you are filling out this form for yourself, "Subscriber", "You" & "Your" are the same. At a minimum, you MUST fill out the Subscriber Information and at least ONE Contact Individual (to be contacted should AlertUSA need assistance with relation to the Subscriber). If your account information changes (new address, phone, etc.), please use the "Account Update" form to alert us of these changes. Please fill out as much of this form as possible. If AlertUSA requires any additional information to start the account, a representative will contact you. If you have any questions, feel free to call us anytime at 1-800-789-6969. You can also call us and sign up over the phone.
Subscriber Name:
E-mail Address:
Street Address:
City:
State:	Zip Code:
Nearest Cross Street:
Date of Birth:
Subscriber Social Security Number: (Recommended, but not required for service.)
Subscriber Home Phone Number:
Subscriber Work Number:
Subscriber Cell Number:
List of Pets:
Primary Language: (if other than English)
Hidden Key Location:
Local Emergency Provider Numbers
If you do not know the Local Emergency Provider Numbers, AlertUSA can provide this information to the Subscriber's account information using our national databases.
Local EMS Phone Number:
Local Fire Station Phone Number:
Local Police Station Phone Number:
Preferred Hospital:
Insurance Carrier:
Private Physician(1):
Specialty:
Contact Number:
Private Physician(2):
Specialty:
Contact Number:
Responders
In the event of an emergency, contact the appropriate emergency services listed above as well as the following responders, listed in order of priority.
First Responder's Name:
First Responder's Home Phone Number:
First Responder's Work Number:
First Responder's Cell Number:
First Responder's Relationship To Subscriber:
Does First Responder Have A Key To Subscriber's Residence?:	YES NO
Second Responder's Name:
Second Responder's Home Phone Number:
Second Responder's Work Number:
Second Responder's Cell Number:
Second Responder's Relationship To Subscriber:
Does Second Responder Have A Key To Subscriber's Residence?:	YES NO
Third Responder's Name:
Third Responder's Home Phone Number:
Third Responder's Work Number:
Third Responder's Cell Number:
Third Responder's Relationship To Subscriber:
Does Third Responder Have A Key To Subscriber's Residence?:	YES NO
Fourth Responder's Name:
Fourth Responder's Home Phone Number:
Fourth Responder's Work Number:
Fourth Responder's Cell Number:
Fourth Responder's Relationship To Subscriber:
Does Fourth Responder Have A Key To Subscriber's Residence?:	YES NO
Additional people to notify in the event of an emergency.
First Additional Name:
Relationship To Subscriber:
Home Phone Number:
Work or Cell Number:
Second Additional Name:
Relationship To Subscriber:
Home Phone Number:
Work or Cell Number:
Third Additional Name:
Relationship To Subscriber:
Home Phone Number:
Work or Cell Number:
Subscriber's Medical Profile
Please list any significant medical conditions:
Please list any allergies (drug/environmental):
Please list any medications the Subscriber is taking:
Name of person filling out this form:
Phone Number:
Relationship to Subscriber (or "self"):
Payment Information
Use the following section to provide us with your payment information. Your credit card will be charged a total of $325.00, which averages $18.75 per month for the year, and a $100.00 refundable deposit. AE107 plans that use DSL phone service require a special filter for an additional $25.00.
	Also send me the optional Lock Box for $35.00.
	Also send me the optional Surge Protector for $5.00.
Name As It Appears On Credit Card:
Credit Card Billing Address:
City:
State:	Zip Code:
Credit Card:
Credit Card Number:
Credit Card Security Number:
Credit Card Expiration Date:
Please retype your full legal name to indicate your approval of credit card use:
The "Terms and Conditions" section is under construction at this time. Forms will be sent to you with your system to review and complete. For now, please enter "mail" in the next two fields.
Type Your Full Legal Name To Accept All The Above Terms And Conditions:
Please Retype Your Full Legal Name To Indicate Acceptance Of Our Terms:
	Click on the SUBMIT button once.

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