Verizon Assumption Of Liability Form – Fill Out and Use This PDF

Transfer of Billing Responsibilit ies E- mail/ Faxback Form

Corporat e t o Personal/ Employee Assumpt ion of Liabilit y rev0 2 0 6 2 0 0 7

This form will allow you to transfer billing responsibilities for a Verizon Wireless mobile telephone number currently held by your employer to you.

1)Complete all the applicable fields below.

2)If you are eligible, or required, to change your calling plan (or if the line you are transferring is the primary line on a Family SharePlan, or is the only secondary line on a Family SharePlan), please review the available calling plans on the Verizon Wireless website at verizonwireless.com. After selecting a calling plan, complete the fields in the Calling Plan Change section below.

3)Read the terms and conditions of this Transfer of Billing Responsibilities Form.

4)Read and accept the Terms and Conditions of the Verizon Wireless Customer Agreement. You may obtain a copy of the Customer Agreement from your Organization or Verizon Wireless representative or online at verizonwireless.com (enter in Customer Agreement in the search field).

5)When returning this form via e-mail you must click the box above the signature line below to acknowledge your electronic acceptance of these terms. Save a copy of the form and upload it to the Verizon Wireless Secure Document Gateway at https://b2b.verizonwireless.com/tbmb/formuploader (address must be manually typed in to your browser). The form should then be e-mailed to MWBSCAOL@VERIZONWIRELESS.COM. E-mails will only be accepted from your Organization’s email domain. Once the form is received, a confirmation e-mail notice will be sent to the requester’s e-mail box.

6)If e-mail process is not available, return this form via Fax, have both parties sign and print at the bottom of this form and fax this form

to:800-387-9291

NOTE: Completion timelines for the Assumption of Liability request is 3-5 business days.

7)

Account Information (Assuming Customer)

Wireless Number to be Transferred:

Create New Billing Account: Yes

No

Assuming Customer Name:

Add to Existing Account Number (if applicable):

Billing Address: (No PO Boxes)

Date of Birth:

Social Security #:

Billing Address (Cont):

E-Mail Address:

City:

State:

Zip Code:

Driver’s License Number:

State:

Primary Address for Use (if different than billing)

Note: No P.O. Boxes:

Home Phone:

City:

State:

Zip Code:

Work Phone:

Calling Plan Change - If Required (Assuming Customer)

Organization Release of Liability (Relinquishing Customer)

•The account identified must be current (no past due balance) before Verizon Wireless can transfer it to another party.

•The individual signing this Transfer of Liability on behalf of Organization represents that they have the legal capacity to bind Organization.

•Organization remains responsible for all charges incurred until the line is transferred.

•By signing this form, or checking the box below, Organization agrees to release liability for the mobile telephone number indicated above. If returning via email, the Organization representative must include their name and date.

If you received this form electronically and are returning via e-mail, please check the box to the left to acknowledge your electronic acceptance of these terms.

Personal/Employee Assumption of Liability (Assuming Customer)

•Upon processing of the transfer of billing responsibilities, a new personal account will be established for you, for this mobile telephone number for which you agree to assume all financial responsibility.

•Establishment of your new personal account is dependent upon a credit check. Some of your personal information above will be used in conjunction with that credit check. A deposit may be required to establish this account.

•Your new personal account requires a minimum of an annual service agreement and you may be subject up to a $175 Early Termination Fee pursuant to the terms and conditions of both the Transfer of Billing Responsibilities and the Customer Agreement.

•If you are receiving discounted monthly access fees as a benefit of your employment: You understand that this discount is based on your organization’s agreement with Verizon Wireless, and that from time to time, your discount rate may be adjusted in accordance with your organization’s agreement. You agree that, if you are otherwise subject to an Early Termination Fee, you will not be permitted to terminate your service without being liable for such Early Termination Fee solely because of a change in your rates resulting from a discount adjustment to which your organization has agreed.

•You understand that certain information relating to your service, including your name, your mobile telephone number and total monthly charge may be released to your organization.

•Verizon Wireless reserves the right to require proof of your employment (Company ID badge or pay stub). If a review of your employment status reveals that you are not, or are no longer, an employee of your organization, Verizon Wireless reserves the right to remove this discount and move you to a commercially available calling plan or to a non-discounted service plan for the remainder of your line term commitment.

If you received this form electronically and are returning via e-mail, please check the box to the left to acknowledge your electronic acceptance of these terms and the Customer Agreement.