Underground Service Request

Basic Account Information

First Name *

Last Name *

Business Name *

Mailing Address *

Mailing Address

City

State/Province

Zip/Postal

Email Address *

Telephone

Telephone Number *

Business Info

If request is for a business, please fill in this section.

Owner Name

Name and phone number of person completing form

Service Request

Service Address

Address where service is to be installed.

Address *

Address

City

State/Province

Zip/Postal

Subdivision or development

Service Description

Lot #

Block

Section

New Service *

Yes

No

Type *

Single Phase

3 Phase

Other Facilities in place

Water lines

Wells

Septic lines

Other

Other facilities marked and located?

Yes

No

Mtr Pan Location Description *

Mtr Pan Location Selection *

A

B

C

D

Select the correct letter from the diagram below that corresponds to the physical location of the or meter pan on the building, relative to the street.

Can temporary service be retired when main service is made hot (active)?

Yes

No

Do you want to add another underground service?

Yes

No

Service Request

Service Address

Address where service is to be installed.

Address *

Address

City

State/Province

Zip/Postal

Subdivision or development

Service Description

Lot #

Block

Section

New Service *

Yes

No

Type *

Single Phase

3 Phase

Other Facilities in place

Water lines

Wells

Septic lines

Other

Other facilities marked and located?

Yes

No

Mtr Pan Location Description *

Mtr Pan Location Selection *

A

B

C

D

Select the correct letter from the diagram below that corresponds to the physical location of the or meter pan on the building, relative to the street.

Can temporary service be retired when main service is made hot (active)?

Yes

No

Do you want to add another underground service?

Yes

No

Service Request

Service Address

Address where service is to be installed.

Address *

Address

City

State/Province

Zip/Postal

Subdivision or development

Service Description

Lot #

Block

Section

New Service *

Yes

No

Type *

Single Phase

3 Phase

Other Facilities in place

Water lines

Wells

Septic lines

Other

Other facilities marked and located?

Yes

No

Mtr Pan Location Description *

Mtr Pan Location Selection *

A

B

C

D

Select the correct letter from the diagram below that corresponds to the physical location of the or meter pan on the building, relative to the street.

Can temporary service be retired when main service is made hot (active)?

Yes

No

Do you want to add another underground service?

Yes

No

Service Request

Service Address

Address where service is to be installed.

Address *

Address

City

State/Province

Zip/Postal

Subdivision or development

Service Description

Lot #

Block

Section

New Service *

Yes

No

Type *

Single Phase

3 Phase

Other Facilities in place

Water lines

Wells

Septic lines

Other

Other facilities marked and located?

Yes

No

Mtr Pan Location Description *

Mtr Pan Location Selection *

A

B

C

D

Select the correct letter from the diagram below that corresponds to the physical location of the or meter pan on the building, relative to the street.

Can temporary service be retired when main service is made hot (active)?

Yes

No

Do you want to add another underground service?

Yes

No

Service Request

Service Address

Address where service is to be installed.

Address *

Address

City

State/Province

Zip/Postal

Subdivision or development

Service Description

Lot #

Block

Section

New Service *

Yes

No

Type *

Single Phase

3 Phase

Other Facilities in place

Water lines

Wells

Septic lines

Other

Other facilities marked and located?

Yes

No

Mtr Pan Location Description *

Mtr Pan Location Selection *

A

B

C

D

Select the correct letter from the diagram below that corresponds to the physical location of the or meter pan on the building, relative to the street.

Can temporary service be retired when main service is made hot (active)?

Yes

No

Certification

CLICK HERE TO READ OUR SERVICE RULES AND REGULATIONS

Member Owned Equipment Update

Agreement *

I have read, understand and agree to abide by the BEMC Service Rules and Regulations. *

Comment

Date of Application *

Acknowledgment *

I acknowledge that all buried utility or existing service lines on my property must be marked with paint or flags prior to BEMC beginning construction. BEMC will not be held responsible for the repair or associated costs of any unmarked lines damaged during the construction process.

Underground Construction Liability Release Form *

By agreeing to service with Brunswick Electric for power to the property listed on the application I hereby release Brunswick Electric Membership Corporation, or its Contractors from any and all damages incurred to driveways, sidewalks, curbs, trees, landscaping and / or water lines, septic tanks, sprinkler lines, or drain fields during requested construction, which have not been properly located, or water wells that have not been identified, while installing underground electric service to. We understand that there may be damage due to installation of underground electrical service along the driveways / sidewalks / curbs or near the bases of trees. Also, Brunswick Electric Membership Corporation, or its contractors, will not be required to replace any landscaping, gravel or stone that is either lost or contaminated due to installation of the underground service.

Signature *

Clear