• Life Support Registration

    Register your life support equipment and contact information to ensure proper notifications and support from HILCO Electric Cooperative.

  • Account Information

  • Format: (000) 000-0000.

  • Contact Information

  • Format: (000) 000-0000.

  • AN EMAIL ADDRESS IS REQUIRED FOR NOTIFICATIONS DUE TO YOUR STATUS. A PHONE NUMBER IS ALSO IMPORTANT TO HAVE ON FILE. PLEASE KEEP YOUR EMAIL ADDRESS AND PHONE NUMBER UPDATED AT ALL TIMES

  • Life Support Details

  • Do you have an emergency back-up in case of an outage?*

  • Authorization

  • CONSUMER STATEMENT

    By signing this statement, I understand that I will be notified by HILCO Electric Cooperative, Inc. (HILCO) of any scheduled outages and that it is my responsibility to provide current and accurate information to HILCO on the status of an unplanned, unscheduled, or emergency outage at my location. I further understand that my life support registration does not guarantee continuous service and will not prevent the termination of my utility service in the event that I fail to meet the payment requirements/obligations on my account. I further understand that I must update this form every 6 months. I will make prior arrangements with the HILCO business office and they will be reasonable with me in trying to work with me to prevent the possibility of termination of service for non-payment. I attest that the information that I have provided is true and accurate.

     

     

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • During times of disaster, with my signature, I authorize HILCO to release my name, address and telephone number to any Emergency Responder

  • Should be Empty: