Protections Application

* indicates required fields

Please select the protection you are looking to apply for from the options below.

Select Desired Protections

Elderly, Blind and/or DisabledLife Support or Medical Emergency

Account Number (Please enter a valid value in the format of 12345-12345):

Account Holder Name:

Account Street Address

City:

State

Zip Code:

Primary Phone Number (Please enter a valid value in the format of 999-999-9999):

Alternate Phone Number (Please enter a valid value in the format of 999-999-9999):

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

EmailUS Mail

Customer Email:

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 , Blind and/or Disabled

The ENTIRE household makeup must consist of any combination of the following.

Elderly - 62 years of age or older and if anyone else is in the home, they are 18 years of age or younger.
Blind - The person has central visual acuity of 20/200 or less in the better eye with the use of a correcting lens or an eye which is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees.
Disabled - Receiving Social Security Disability (SSD), Supplemental Security Income (SSI) or Military Benefits due to a service-related disability.

Please list names of ALL household members below and check all that apply.

Name	Date of Birth	62 Plus	18 or under	Blind	Permanently Disabled
		Yes	Yes	Yes	Yes

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

Elderly	• Driver’s License • Military ID • Birth Certificate • Marriage License • Passport
Blind	• Medical letter signed by physician
Disabled	• Copy of SSI or SSD award letter or proof of military or service-connected disability from the VA

Upload Proof for Resident ONE:

Upload Proof for Resident TWO:

Upload Proof for Resident THREE:

Upload Proof for Resident FOUR:

Check to Add Proof Upload for Additional Residents

Upload Proof for Additional Residents:

Life Support or Medical Emergency

Life Support - Someone in the household relies on electrically operated life-sustaining medical equipment and would require immediate hospitalization if electric service is interrupted.
Medical Emergency - Any other medical need for utility services.

Patient Name:

Patient Date of Birth:

Relationship to Account Holder:

Doctor Name:

Doctor Phone Number (Please enter a valid value in the format of 999-999-9999) :

Doctor Fax Number (Please enter a valid value in the format of 999-999-9999) :

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Protections Application