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First Name*:

Last Name*:

SERVICE ADDRESS
Street*:

City*:

State*:

Zip Code (ex. 12345)*:

If Mailing Address is Different Than Service Address
MAILING ADDRESS
Street:

City:

State:

Zip Code (ex. 12345):

TELEPHONE NUMBER (ex. 412-555-1212)
Daytime*:

Evening:

E-MAIL
E-mail Address*:

Are you a Peoples Gas (formerly Equitable Gas) Customer?
—Please choose an option—YesNo

If Yes, Account Number? (12 digits)

If No, who provides your gas service?
—Please choose an option—Columbia GasPeoples GasT.W. Phillips Gas

Choose the Protection Program(s) you are signing up for
(please check all that apply)
Gas Service Line ProtectionWater Service Line ProtectionGas In-House Line ProtectionGas Underground House Line ProtectionGas Service Line Protection Restoration ProtectionWater Service Line Protection RestorationUnderground House Line Protection RestorationSewer Service Line ProtectionHeating ProtectionCooling ProtectionHeating/Cooling Protection

Choose payment option
Monthly Billing (only available for Peoples, formerly Equitable Gas, customers)Prepay 6 monthsPrepay 12 months

For prepay 6 or 12 months, payment will be by
Personal Check (payable to Reliable HOMEWORKS)

How did you hear about our protection programs?

Are you the property owner?
—Please choose an option—YesNo

Is this a residential single family dwelling?
—Please choose an option—YesNo

What year was your home built?

Have you had any problems with your sewer service line in the last 3 years (internal, external, roots, other)?
—Please choose an option—YesNoN/A

Where is your gas meter located?
—Please choose an option—InsideOutside next to the houseOutside at the road

Where is your water meter located?
—Please choose an option—InsideOutside next to the houseOutside at the road

If this is for water service line, what is the name of your water company?