Broadband Service Application
Please complete the below application to apply for service with LaGrange County REMC. NOTE: All fields with RED (*) are required. After hitting submit, you should get a confirmation email. If you do not, then the application has not been submitted.

If you have any questions regarding new service, please feel free to contact customer service during normal business hours at (877) 463-7165 or send an email to customerservice@lagrangeremc.com.

To select your package please first select the service(s) you want and then use the binoculars to select the package you want. To see our packages and what is included please click here.

To view our broadband labels: https://www.lagrangeremc.com/broadband-labels


For Date Service is Desired, if your property is currently ready to receive service, select today’s date.  Installations will be scheduled with you as our crews are available.  If your property is not currently ready for installation (new construction, moving to new location), please select the date when you expect to be ready for installation.

Today's Date:  
Date Service is Desired:  *  
Type of Request:  
Services:      *
Applicant:
First Name:		   *
Last Name:   *
Middle Initial:  
Social Security Number:--  *
Date of Birth:
Example format (xx/xx/xxxx)		  *  
How many people are in your household?  *
Standard Service Drop Construction
Drop construction is the installation of fiber optic cable from the road’s edge through your property ending at our Network Interface Device (NID) to be installed on the side of your house. Our free standard construction of the fiber service drop will generally follow the shortest and most economic path available, and we will install the NID near the existing electric meter on your house or near other existing utility entrances.  The fiber service drop will be constructed aerially/overhead whenever possible, even if your other utilities are buried.  
  • Please indicate YES in the box if you agree to standard drop construction at your location.
  • Please indicate NO in the box if you believe standard construction may not be practical at your location and we will schedule a preconstruction meeting with you.  There may be additional charges if standard construction cannot be used at your location or if you require alternative installation methods.
PLEASE NOTE: You are responsible for locating all private underground facilities (lawn sprinkler/irrigation, septic systems, drainage tiles, dog fences, etc) prior to construction.  Neither REMC nor the drop construction contractor is responsible for damage to unlocated facilities.		  *

Mailing Address:
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address:
Please enter the street address where service is required:
Service Address:   *
Comments:  
E-mail:  *
Confirm E-mail:  *
Home Phone:--   *
Cell Phone:--  
Work Phone:
*if home phone and cell phone are the same, please enter number in both fields to ensure accurate correspondence		--   
Spouse:
First & Last Name:		 
Social Security Number:-- 
Date of Birth:
Example format (xx/xx/xxxx)		    
Secondary Email:  
Confirm Secondary Email:  
Other Phone:  
Electronic Signature: I understand that by typing my name, as the listed Spouse, in the field provided that this is electronic signature and that I agree to all terms and conditions herein as coapplicant.
*Required if Spouse		  

Online Access:
We offer a web portal and mobile app for access to your payment options, account management and easy access to your ebill. If you would like to access your account online, please create a password and password hint below. For security purposes, a minimum password length of 10 characters and a combination of uppercase letters, lowercase letters, numbers, and symbols (!@#$%^&*) is required.

IMPORTANT NOTE: If you already have online access set up for your electric account, please disregard this section as the same login access will be used to manage both your electric and fiber accounts.
Internet Password:  
Confirm Internet Password:  
Password Hint:

Description - Phone Charge
Additional Voicemail 10.00

 

Description - Internet Charge
Parental Controls 6.95
Network Protection 6.95


Additional Items:
Are you interested in any of the items below for an additional monthly fee?
Phone/Additional Voicemail $10.00
(indicate yes or no)		  *
Internet/ProtectIQ $6.95
Network Protection
(indicate yes or no)		  *
Internet/ExperienceIQ $6.95
Parental Controls
(indicate yes or no)

  *
Account Alerts:
All account alerts are sent via email. Would you like text alerts as well?
(Please indicate yes or no)		  *
If you would like text alerts, please confirm phone number:  
If you selected yes for our VOIP/phone services; would you like to keep your same phone number?
(indicate yes or no)		  
Do you rent or own the service location?   *
Please select your preferred Billing Method:
Please Note: You will receive all bills via email, unless you request otherwise. Paper billing is an additional monthly charge.
*All LaGrange County REMC Electric Members will receive their electric and fiber bill together via email in an invoice format unless requested otherwise.		  
 
The undersigned applicant, in exchange for the provision of broadband internet services, hereby agrees to the following conditions:
  • The applicant will comply with all applicable law, policies, and legally binding agreements regarding the LaGrange County REMC,
  • The applicant will, at prices, rates or amounts determined by LaGrange County REMC Board of Directors, and in a manner specified by LaGrange County REMC, pay the LaGrange County REMC for service, assessments, fees, deposits, contributions, or other amounts required,
  • The applicant complete any additional or supplemental document or contract required by LaGrange County REMC pursuant to the bylaws and policies created by the Board of Directors
  • The applicant understands that using broadband services does not convey or entitle the applicant the rights of membership in the Cooperative.
  • Upon acceptance by the Cooperative, the applicant agrees to be bound by the Broadband Service Agreement.
I understand that checking this box and typing my name in the field provided below is my electronic signature.
  Applicant Name:     *