* indicates required fields

Customer First Name

Customer Last Name (as shown on the National Grid bill statement)

Service Address (as shown on the National Grid bill statement)

City (as shown on the National Grid bill statement)

State

Zip

Daytime Phone

Mobile phoneLandline

Mobile Phone (Please enter a valid value in the format of 999-999-9999)

Landline (Please enter a valid value in the format of 999-999-9999)

Account Number (Please enter numbers only without the dash)

Meter Number (Electric - this can found on the National Grid bill statement)

Do you operate life support or other sensitive medical equipment in your home?

YesNo

Reason for opting out

Reason for requesting opt out

Please explain

Opt-out requests may take up to 7 business days to process. If a technician arrives at your home for installation and you've requested to opt-out, kindly state that you have completed the opt-out request form online and the technician will move on to other customer installations.