Homeowner or Business

Homeowner or Business
Personal Guarantee?
Customer Name *
SSN
Date of Birth
Phone / Email *
Name of Business / Type *
Business Title *
Preferred Password *

Spouse/Resident

Spouse/Resident Name
SSN
Date of Birth
Phone/Email

Contact List

NameTelephone #ExtTypeUser #Password 
 
 
 
 
 

Premise Address

Address *
City *
Zip/Postal Code *
County

Billing Address

Same as Premise
Address *
City *
Zip/Postal Code *
County

Home Address

Address *
City *
Zip/Postal Code *

Installation Dates

Installation Date *
Installation End Date *
Signing Location *

Guard Addendum

Include Guard Addendum
Gate Code

Company Information

* This agreement complies with the Pennsylvania Home Improvement Consumer Protection Act (the "Act"). The Customer may verify that the Company is registered under the Act by calling 888-520-6680.
Registration Number

Insurance

* Contractor agrees to maintain liability insurance covering personal injury in an amount not less than $50,000, and insurance covering property damage cause by the Work to be performed under this Contract in an amount not less than $50,000
Personal Injury Amount
Property Damage Amount

Equipment List

Cellular Included? *
NamePtsQtyPriceTotal
Subtotal
Other
Permits
Tax
Total
Description of work to be completed

Monitoring Terms

Number of Payments *
Monthly Monitoring Rate *
 (total monthly fee)
Promotion / Member ID
Discount Amount
Cust. Billed New Rate
One Time Activation Fee *
Months Paid Upfront
Promotion Period
Bill Start Date
Extended Service Option: *
*Option ($75 Trip Charge) - Residential Only

Cellular Communication

Vendor (Selection)

Financial Disclosure


Financial Disclosure Statement
THERE IS NO FINANCE CHARGE OR COST OF CREDIT (0%) ASSOCIATED WITH THIS AGREEMENT
A. Number of Payments for the initial term is   B. Amount of each payment is $ 
(Total Monthly Fee from Terms Tab)		 Total of payments for the initial term is $  (AxB)
(Plus applicable levies, charges, taxes, fees, fines, and rate increases)
Late Charge - Company may impose a late charge of up to $5 on each payment that is more then ten (10) days past due. Pre Payment - If you prepay amounts due under this agreement there is no penalty or refund See section 8 of this agreement for information about non payment, default and liquidated damages

Billing Information

By signing this Agreement, Customer acknowledges and agrees that Company is authorized to deduct the Initial Payment from the Account provided below.
Initial Payment
$0.00 (Prepaid Monitoring + Activation Fee + Equipment Total)
Payment Type
Bank Account Credit Card
Bank Account #
Branch #
Institution #
ABA Routing #
Credit Card Type
Credit Card #
Expiration Date
/
By signing this Agreement, Customer acknowledges and agrees that Company is authorized to deduct the monthly monitoring fee (plus any applicable levies, charges, taxes, fee, fines and rate increases) from the Account provided below.
Same as Initial Payment
Monthly Billing Amount
$0.00 (total monthly fee)
Payment Type
Bank Account Credit Card Monthly Invoice
Bank Account #
Branch #
Institution #
ABA Routing #
Credit Card Type
Credit Card #
Expiration Date
/
Draft Date

Attachments

Attachment 1

Attachment 2

Attachment 3

Attachment 4

Attachment 5

Customer Authorization

Are you the homeowner?
Is your home new construction?
Are you under any contractual/obligation with any other company for monitoring services?
I understand that   or any representative of  , cannot be responsible for cancelling any services with my current security company (If Applicable)
I understand that I have signed an agreement to receive monitoring for   months.
A familiarization period is recommended to allow you to become familiar with the use of your security system and to avoid false alarms and potential fines. Do you authorize us to configure a 7 day familiarization period?

Contract Information Review

   

ELECTRONIC RECORD AND SIGNATURE DISCLOSURE

From time to time, the company you are contracting with (referred to sometimes as, “we”, “us” or “Company”) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through your email address provided herein or your DocuSign, Inc. (DocuSign) Express user account. Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to these terms and conditions, please confirm your agreement by clicking the 'SIGN CONTRACT' button.

Getting paper copies

At any time, you may request from us a paper copy of any record provided or made available electronically to you by us. For such copies, as long as you are an authorized user of the DocuSign system you will have the ability to download and print any documents we send to you through your DocuSign user account for a limited period of time (usually 30 days) after such documents are first sent to you. After such time, if you wish for us to send you paper copies of any such documents from our office to you, you will be charged a $0.00 per-page fee. You may request delivery of such paper copies from us by following the procedure described below. You may also request paper copies by sending notice electronically to [email protected] or in writing to P.O. Box 814530, Dallas, Texas 75381-4530 and in the body of such request you must state your e-mail address, full name, US Postal address, and telephone number.

Withdrawing your consent

If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. How you must inform us of your decision to receive future notices and disclosure in paper format and withdraw your consent to receive notices and disclosures electronically is described below.

Consequences of changing your mind

If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can complete certain steps in transactions with you and delivering services to you because we will need first to send the required notices or disclosures to you in paper format, and then wait until we receive back from you your acknowledgment of your receipt of such paper notices or disclosures. To indicate to us that you are changing your mind, you may withdraw your consent by sending notice electronically to [email protected] or in writing to P.O. Box 814530, Dallas, Texas 75381-4530. This will indicate to us that you have withdrawn your consent to receive required notices and disclosures electronically from us and you will no longer be able to use your email or your DocuSign Express user account to receive required notices and consents electronically from us or to sign electronically documents from us.

All notices and disclosures will be sent to you electronically

Unless you tell us otherwise in accordance with the procedures described herein, we will provide electronically to you through your email address and/or your DocuSign user account all required notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you during the course of our relationship with you. To reduce the chance of you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required notices and disclosures to you by the same method and to the same address that you have given us. Thus, you may receive the disclosures and notices electronically or in paper format through the paper mail delivery system. If you do not agree with this process, please let us know as described below. Please also see the paragraph immediately above that describes the consequences of your electing not to receive delivery of the notices and disclosures electronically from us.

To advise the Company of your new e-mail address

To let us know of a change in your e-mail address where we should send notices and disclosures electronically to you, you must send an email message to [email protected] or in writing to P.O. Box 814530, Dallas, Texas 75381-4530 and in the body of such request you must state: your previous e-mail address, your new e-mail address. We do not require any other information from you to change your email address.

In addition, you must notify DocuSign, Inc to arrange for your new email address to be reflected in your DocuSign account by following the process for changing e-mail in DocuSign.

Required hardware and software

Operating Systems: Windows® 2000, Windows® XP, Windows Vista®; Mac OS® X
Browsers: Final release versions of Internet Explorer® 6.0 or above (Windows only); Mozilla Firefox 2.0 or above (Windows and Mac); Safari™ 3.0 or above (Mac only)
PDF Reader: Acrobat® or similar software may be required to view and print PDF files
Screen Resolution: 800 x 600 minimum
Enabled Security Settings: Allow per session cookies

Users accessing the internet behind a Proxy Server must enable HTTP 1.1 settings via proxy connection

** These minimum requirements are subject to change. If these requirements change, we will provide you with an email message at the email address we have on file for you at that time providing you with the revised hardware and software requirements, at which time you will have the right to withdraw your consent.

Acknowledging your access and consent to receive materials electronically

To confirm to us that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you, please verify that you were able to read this electronic disclosure and that you also were able to print on paper or electronically save this page for your future reference and access or that you were able to e-mail this disclosure and consent to an address where you will be able to print on paper or save it for your future reference and access. Further, if you consent to receiving notices and disclosures exclusively in electronic format on the terms and conditions described above, please let us know by clicking the 'I agree' button on the previous page.

By clicking the 'SIGN CONTRACT' button, I confirm that:

I can access and read this Electronic CONSENT TO ELECTRONIC RECEIPT OF ELECTRONIC RECORD AND SIGNATURE DISCLOSURES document; and

I can print on paper the disclosure or save or send the disclosure to a place where I can print it, for future reference and access; and

Until or unless I notify the Company as described above, I consent to receive from exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to me by the Company during the course of my relationship with you.

Installation Agreement

1. This Installation Agreement (the "Agreement") is made as of   by and between  , the "Company" and the "Customer" listed below who owns the residence or business located at the address shown below (the "Premises"). This agreement complies with the Pennsylvania Home Improvement Consumer Protection Act (the "Act"). The Customer may verify that the Company is registered under the Act by calling 888-520-6680. The Company's registration number is  
Home or business owner
Address
 
City / State
Zip / County
Email Address
Preferred Password
Premise Phone
Spouse Phone
Preferred Language
Registration Number
Contact List
NameTelephone #ExtTypeUser #Password
      
      
      
      
      
Equipment
NamePtsQtyPriceTotal
     
     
     
     
     
     
     
     
     
     
   Subtotal 
   Other 
   Permits 
   Tax 
   Total 
Description of Work to be Completed

Approximate Start Date/Completion Date

Appx. Installation Start Date
 
Appx. Installation Completion Date
 

Insurance

* Contractor agrees to maintain liability insurance covering personal injury in an amount not less than $50,000, and insurance covering property damage cause by the Work to be performed under this Contract in an amount not less than $50,000

Current Amount of Personal Injury Insurance
 
Current Amount of Property Damage Insurance
 

Survey

Are you the homeowner?
 
Is your home new construction?
 
Are you under any contractual/obligation with any other company for monitoring services?
 
I understand that   or any representative of  , cannot be responsible for cancelling any services with my current security company (If Applicable)
 
I understand that I have signed an agreement to receive monitoring for   months.
 
Billing Information
Monitoring Fee
$0.00
Activation Fee
$0.00
Equipment Fee
$0.00
Total Payment Due
$0.00
Customer acknowledges that the Company has authorization to deduct the Total Payment Due from the Account listed below:
Payment Type
Bank Account #
ABA Routing #
Credit Card Type
Credit Card #
Expiration Date
Billing Address
Address
 
City
 
State
 
Zip
 
Customer Authorization
 I have read the terms of the Installation Agreement
Complaints against the Company may directed to the Pennsylvania Bureau of Consumer Protection at 1-800-441-2555.

Dealer Representative

Salesperson Name
State ID Number

Binding Arbitration

THE PARTIES AGREE TO RESOLVE THROUGH BINDING ARBITRATION ALL SUITS, CAUSES OF ACTION, CONTROVERSIES, CLAIMS, DISPUTES, DIFFERENCES, DISAGREEMENT OR MATTERS AT ISSUE (COLLECTIVELY REFERRED TO AS “CLAIMS”), WHETHER OR NOT THEY ARISE BY VIRTUE OF THIS AGREEMENT, ARE OF AN EXTRACONTRACTUAL, CONTRACTUAL OR OTHER NATURE, ARISE BY VIRTUE OF REGULATIONS OR COMMON LAW, THAT THE PARTIES MAY HAVE BETWEEN THEMSELVES AND THEIR RESPECTIVE PRINCIPAL ORGANIZATION, SUBSIDIARIES AND AFFILIATES AS WELL AS WITH THE OFFICERS, DIRECTORS, EMPLOYEES OR AGENTS ACTING WITHIN OR OUTSIDE OF THE SCOPE OF THEIR CAPACITY. THE PARTIES AGREE THAT ARBITRATION SHALL BE CONDUCTED ACCORDING TO FEDERAL ARBITRATION ACT (“FAA”), UNLESS THE MATTER IN ARBITRATION IS NOT COVERED UNDER FAA, IN WHICH CASE THE ARBITRATION WILL BE CONDUCTED IN ACCORDANCE WITH THE APPLICABLE COMMERCIAL ARBITRATION RULES OF THE AMERICAN ARBITRATION ASSOCIATION (“AAA”). IF ONE OF THE PARTIES REFUSES TO HONOR ITS OBLIGATION UNDER THIS ARBITRATION AGREEMENT, THE OTHER PARTY MAY COMPEL ARBITRATION IN STATE OR FEDERAL TRIBUNALS IN DALLAS, TEXAS TO WHICH JURISDICTION BOTH PARTIES VOLUNTARY SUBMIT. THE ARBITRATOR SHALL APPLY THE SUBSTANTIVE LAW OF THE STATE OF TEXAS (EXCLUDING THE SELECTION OF LAW PRINCIPALS, THAT TEXAS MAY PROVIDE FOR, RELATING TO THE APPLICATION OF LAW FROM OTHER STATES), OR FEDERAL LAW, OR BOTH, AS APPLICABLE TO THE AFFIRMED CLAIMS. NOTWITHSTANDING THE AFOREMENTIONED, THE ARBITRATOR IS NOT AUTHORIZED TO GRANT PUNITIVE DAMAGES WITH RESPECT TO ANY CLAIM. THE COSTS OF ANY ARBITRATION, INCLUDING REGISTRATION AND TRANSCRIPTION COSTS, ADMINISTRATIVE COSTS, ATTORNEY FEES, AND ALL OTHER FEES AND COSTS, SHALL BE PAID BY THE NON-PREVAILING PARTY AS DETERMINED BY THE ARBITRATOR, OR SHALL BE LEVIED IN AN EQUITABLE MANNER AS DETERMINED BY THE ARBITRATOR. THE ARBITRATOR SHALL HAVE THE EXCLUSIVE AUTHORITY TO RESOLVE ANY DISPUTE RELATING TO THE INTERPRETATION, APPLICABILITY OR FORMATION OF THIS ARBITRATION AGREEMENT, INCLUDING ANY CLAIM ALLEGING THAT ALL OR PART OF THIS AGREEMENT IS NULL OR VOIDABLE. ALL THE PROCEEDINGS CONDUCTED UNDER THIS ARBITRATION AGREEMENT, INCLUDING ANY ORDER, DECISION OR AWARD BY THE ARBITRATOR, SHALL BE HELD IN CONFIDENCE BY THE PARTIES.
Customer Signature
 
Company Authorized Signature
 
Customer Authorization
 I have read the terms of the Binding Arbitration Agreement
Dealer Security Login
 
User Name
Password
State ID Nbr  Not Required
  
Brinks Home Security eContract
To access eContract you must have a signed Non Solicit Agreement on file. It can be quickly sent to you via email.

We have your email as the following: (no address found on file). To use a different email, please enter the new address in the text box below.
Email Address 
To receive the agreement via email select Submit:
   
Country / Language
 
Premise Country
Preferred Language
Credit Authorization Form
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