Critical Needs Form

Printable Form

The Algoma Utilities maintains a “Critical Needs” customer list. During the summer months, there is an increased probability that utility system emergency conditions could develop. Algoma Utilities, together with our electric power supplier, WPPI Energy, continuously monitor all conditions. We will make every effort to avoid interrupting your service. However, emergency conditions beyond our control could result in your power being interrupted. Please complete the Critical Needs Form below or download the printable form above if special circumstances exist in your home or business that make the loss of electricity or water critical.

Critical Needs Form

Name(Required)

First Last

Account Number(Required)

Service Address(Required)

Street Address City State ZIP Code

Phone(Required)

Country Phone Number

Email(Required)

The following person is using life-sustaining equipment at the above service address

Patient's Name(Required)

First Last

Date of Birth(Required)

Doctor's Name(Required)

First Last

Phone(Required)

Country Phone Number

Medical Condition(Required)

Type of Equipment Needed(Required)

I do have a battery backup(Required)

Yes

Number of hours(Required)

Other circumstances in which health conditions could be aggravated by loss of electric or water service

Elderly Person in the home with poor health condition

First Last

Infant in the home with poor health condition

First Last

List of other special/unusual circumstances

THIRD PARTY NOTIFICATION - is there someone who should be contacted in the event of electric or water service being disconnected and wer are unable to reach you?

Name

First Last

Address

Street Address City State ZIP Code

Phone

Country Phone Number

Release (e-signature from patient with condition or his/her legal guardian

E-signature(Required)

First Last

Date(Required)