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Request to Disconnect Line
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Vendor fax number
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Disconnect
Telephone number
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Site name
Disconnect
Telephone number
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Site name
Disconnect
Telephone number
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Site name
Final bill address
Street address
City State ZIP code
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Desired disconnect date
Month Day Year
Requesting company
Authorized signature Date
Name (typed)
Contact number
Ext.
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Comments
Is this a seasonal disconnect?
Please choose
Yes
No
Reconnection date
Month Day Year

Reconnection date cannot exceed 180 days from disconnect date.

This form requires a signature and cannot be submitted electronically.

Please fill out the above form and click on the "next" button below. This will allow you to see the results of your entries exactly as they will appear when printed. After your review, simply print this completed form from your browser and fax or mail it to NPCC at the address below.

Please keep a copy for your records.

Please fax or mail to:
Verizon NPCC
110 E. Monroe St.
MC: ILLLBMH
Bloomington, IL 61701
Fax: 1-800-483-4534
Phone: 1-800-483-2678
E-mail us using our electronic form.

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