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Formerly Sand Prairie
Formerly JISP
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About JCE
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Touchstone Energy
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Priority Electric Service
To be Completed by Member
Member Name:
Home Address:
Email Address:
Account Number:
Primary Phone:
Secondary Phone:
Is a generator installed at your location?
Yes
No
I don't know
If you answered “No” or “I don’t know” to the above, do you have a battery back-up for medical equipment?
Yes
No
Emergency (Secondary) Contact Information
Please provide an emergency (secondary) contact, in the instance that we need to reach you for a long-duration preventative or emergency outage. This contact information will only be used to reach you, and not be permitted to any information related to your account status, unless you otherwise authorize such account-level access. You may leave this section blank if you so choose.
Emergency Contact Name:
Mailing Address:
Emergency Contact Home Address:
Primary Phone:
Secondary Phone:
Medical Condition Information
I have a medical condition that is:
CHRONIC: The patient has a serious medical condition that requires an electric powered medical device or electric heating or cooling to prevent impairment of a major life function through a significant deterioration or exacerbation of the person’s medical condition.
Has the chronic medical condition been diagnosed as a life-long condition?
Yes
No
CRITICAL CARE: The patient is dependent upon an electric-powered medical device to sustain life.
Has the critical care medical condition been diagnosed as a life-long condition?
Yes
No
Physician's Name:
Acknowledgement
I acknowledge that JCE Co-op cannot guarantee uninterrupted electric service. Nor can the cooperative promise that there won’t be extended outages even if I am on this priority list. I recognize it is my responsibility to have arrangements to tolerate a widespread and lengthy service outage.
