LifeGuardian Subscriber Billing Update Form

Simply and quickly update subscriber information!

Please take a minute to complete the Update Subscriber Billing Form and your order will be transmitted electronically direct to the LifeGuardian accounting office. Updates are generally inputted into the system within one business day.

If you prefer, click here to print out, mail or FAX your Update Subscriber Information Form.

Please Note: * Indicates required field.

1. SUBSCRIBER INFORMATION
LifeGuardian Account Number:
*Subscriber (User) Name:
*Physical Address:
Apartment/Unit #:
*City
*State:
*Zip Code:
*Telephone Number: (Please Include Area Code)
2. BILLING INSTRUCTIONS
Bill To Subscriber                 Bill To Another (complete below)
Full Name:
Billing Address:
City:
State:
Zip Code:
Phone Number:
3. Credit Card Deduction
Credit Card
Name On Card
Card Number:
Expiration Date:
Card CVN Number  (3-4 Digit Security Code On Back)
OR
4. Bank Account Deduction
Deduct From Checking/Savings Account (Please FAX a voided check to 800-209-3813)
Bank Name:
Account Number:
Routing Number:
5. APPROVAL AND ACCEPTANCE
Subscriber, or their legal or authorized legal representative, hereby acknowledges that they have received, read, understand and accept without limitation or exception, the Subscriber Service Agreement Terms and Conditions. I agree that ordering, receipt, activation, testing or use of my System constitutes its acceptance of this Agreement and all future updates to this Agreement, as published by LifeGuardian Technologies, LLC, and it shall be binding and effective upon either execution date below or the delivery date of my System whichever occurs first. I authorize LifeGuardian Technologies, LLC. or its assignee, Monitoring Services, to initiate and commence ongoing electronic debits from my credit card or bank account for all amounts I owe under this agreement as directed above. I understand the monthly, quarterly or annual service plan selected above will renew automatically until I cancel this authorization through written notice 30 days in advance of the next billing period. I have been given the opportunity to read and make a copy this agreement prior to activating my LifeGuardian account.
*Agreement Acceptance
*Accepted By (Type Name):
*Date Completed:
*Phone Number:
*Email Address
Referred By:
Referrer's Phone Number: