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Home Billing & Payments Help Making Payments Special ProtectionsCustomer Protections Form

Customer Protections Form

Special Protections Customer Protections Form

Please select the protection you are looking to apply for from the options below. For each protection you will be required to submit the relevant documentation for proof. If you are NOT on the low-income Discount Rate you will also have to submit your Financial Hardship statement below.

Select Desired Protections:

Elderly/Elderly w MinorMedicalInfant

Is your service currently on or has it been shut off for non-payment?

My service is currently onMy service has been shut off for non-payment

Which Account Will you be Claiming Protections?

ElectricGasBoth Gas and Electric

Electric Account Number:

Please enter a valid value in the format of 12345-67890

Gas Account Number:

Please enter a valid value in the format of 12345-67890

Account Holder Name:

Account Street Address:

City:

State:

Zip Code:

Patient Name (if not account holder):

Parent Name (if not account holder):

Customer Email:

How would like to receive updates regarding your protections application status?

EmailUS Mail

Important Notice! By selecting email you are opting to receive electronic communication from National Grid only for this protections application information, we will not use this email to contact you for other purposes unless you have opted in elsewhere.

Elderly/Elderly w Minor Protections

Select Elderly OR Elderly w Minor Protections

Elderly Protection - A household qualifies for Elderly Protections when ALL members of the household are age 65 years or older. To apply please submit one of the following forms of proof of age for each member of your household. Elderly Protection with Minor Protection - A household qualifies for Elderly with Minor Protections when ALL members of the household are over 65 and/or under 18 years of age. To apply submit one of the following forms of proof of age for all members of the household.

Please Provide Proof from One of The Following for Each Household Member:

• Driver’s License • Military ID • Birth Certificate • Marriage License • Passport

Upload Proof of Age for Resident ONE:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Upload Proof of Age for Resident TWO:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Upload Proof of Age for Resident THREE:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Upload Proof of Age for Resident FOUR:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Upload Proof of Age for Minor Resident:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Upload Proof of Age for Minor Resident:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Check to Add Proof Upload for Additional Residents

Upload Proof of Age for Additional Residents:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Medical Protections

Medical Protection - A household qualifies for a serious illness protection when a doctor or licensed medical professional confirms a patient with a serious or chronic illness resides in that household. Proof required must be on Medical Professionals Letterhead, include a signature (or e-signature) of a Doctor (MD), Nurse Practitioner (NP), Physicians Assistant (PA), or local Board of Health signature. It must state the name and address of seriously ill person and whether the illness is serious (90 day protection) or chronic (180 day protection).

Please select which document you are uploading below:

Medical Letter (from Doctor, medical professional, etc) Letter from local Board of Health

Upload Proof of Medical Letter:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Upload Letter from local Board of Health:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Infant Protections

Infant Protections - A household qualified for Infant protection when a child under 12 months of age resides in the household. A valid birth certificate or a letter or official documents issued by a registered physician, physicians assistant, nurse practitioner, local board of health, hospital or government official, Dept of Transitional Assistance, clergyman, or Religious institution is required to qualify.

Please choose which document you are uploading below:

Birth CertificateLetter from Medical ProfessionalHospital Proof of BirthReligious DocumentationGovernment Document (Dept of Transitional Assistance etc)

Upload Photo Copy of Birth Certificate:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Upload Photo Copy of Letter from Medical Professional:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Upload Photo Copy of Hospital Proof of Birth:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Upload Photo Copy of Religious Documentation:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Upload Photo Copy of Government Document:

File extensions allowed: .jpg, .jpeg, .png, .tif, .pdf

Financial Hardship Form

Please indicate below whether your National Grid Account is on a Low-Income Discount Rate. If you are NOT on the low-income rate you're required to fill out the Financial Hardship statement below. If you are unsure select no and fill out the following form to ensure quick processing time for your protection claim.

Select one.

Yes, my account is currently on National Grid's Low-Income Discount RateNo, my account is NOT on National Grid's Low-Income Discount Rate

Please list ALL people living in your household (including children). If they receive income, list the income source, amount and when received. (Click the Add Addition Person link below to list additional people.)

Household Person Information

Name:

Date of Birth:

Income Source:

Amount:

Income Received:

WeeklyBi-WeeklyMonthlyYearly

Household Person Information

Name:

Date of Birth:

Income Source:

Amount:

Income Received:

WeeklyBi-WeeklyMonthlyYearly

Household Person Information

Name:

Date of Birth:

Income Source:

Amount:

Income Received:

WeeklyBi-WeeklyMonthlyYearly

Household Person Information

Name:

Date of Birth:

Income Source:

Amount:

Income Received:

WeeklyBi-WeeklyMonthlyYearly

Click to Certify Information as True:

Yes, I certify that the information provided above is complete and true to the best of my knowledge.
(National Grid reserves the right to request documents to support this information.)

Third Party Information

The Third Party program allows you to select a person to act on your behalf if you receive a collection notice from us. We will send a copy of any collection notice to your third party who can look into the situation and help make arrangements. The third Party can be a trusted friend or relative. However, the third-party is NOT responsible for nor obligated to pay your bill.

I would like to add a Third Party

I designate the following person to be contacted for Third Party Notification. I Understand that the contact person is not responsible for paying my National Grid Bills

Third Party Information

Third Party Name

Third Party Street Address

City

State

Zip Code

Email address (optional)

Telephone Number

Please enter a valid value in the format of 999-999-9999.

Special Protections Customer Protections Form

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