Customer Information (step 1 of 3)
First name
*
Last name
*
Account number
*
Email
*
Phone number
*
Alternate contact number
Address where you receive gas service (step 2 of 3)
House number
*
Street
*
Unit/lot/suite
City
*
State
*
Missouri
ZIP code
*
About the emergency (step 3 of 3)
First name
*
of person with medical emergency
Last name
*
of person with medical emergency
Relationship to customer
*
Description of medical emergency
*
up to 500 characters
I represent that a medical emergency exists at my residence and that discontinuance of gas service will aggravate this medical emergency.
*
*
Required
Next step
Send
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