Agent Info
*
First Name
Last Name
EBQ Email Address
*
EBQ Email Address
Customer Info
*
Company Name
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Maine
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Michigan
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Ohio
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Info
*
First Name
*
Last Name
Business Email
Contact Email
*
-
Area Code
Phone Number
*
Call Detail Notes
0/0
Preferred method of contact
*
Phone
Email
Contact
*
ASAP
Specific date and time
Date
*
/
Month
/
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
PM
AM/PM Option
Utility & Account Information
Utility
*
Please Select
Pepco DC
ComEd
Ameren
National Grid Massachusetts
Eversource Western Massachusetts
Pepco MD
Delmarva
Potomac Edison
BGE
Detroit Edison
Consumers Energy
National Grid
NYSEG
RG&E
Orange and Rockland
Con Edison
Duke Energy
AEP Ohio
Toledo Edison
Illuminating Company
Ohio Edison
DPL
PECO
PPL
Account Number
*
Should be a 10 digit number
Acct Number
*
Should be a 9 or 10 digit number
Acct. Number
*
Should be a 15 digit number
Account #
*
Should be a 10 or 11 digit number
PoD ID
*
Should be a 'N01' immediately followed by a 12 digit number (Accounts starting with N02 are GAS and are not valid for electricity service)
POD ID
*
Should be a 'R01' immediately followed by a 12 digit number
Service Delivery Identifier (SDI)
*
should be a 17 digit number starting with 0004 or 0014
Customer Number
*
Should be a 20 digit number
Meter Number
*
Should contain only numbers and letters
PLEASE NOTE: Add additional account numbers in 'Call Detail Notes'
1
Current Rate
Currently in contract?
*
Yes
No
Current Supplier
Contract End Date
Please Select
January 2016
February 2016
March 2016
April 2016
May 2016
June 2016
July 2016
August 2016
September 2016
October 2016
November 2016
December 2016
January 2017
February 2017
March 2017
April 2017
May 2017
June 2017
July 2017
August 2017
September 2017
October 2017
November 2017
December 2017
January 2018
February 2018
March 2018
April 2018
May 2018
June 2018
July 2018
August 2018
September 2018
October 2018
November 2018
December 2018
Bill Copy
Add additional files?
Yes
No
Bill Copy 2
Bill Copy 3
Bill Copy 4
Bill Copy 5
Bill Copy 6
SUBMIT
Should be Empty: