Please Print or Type
Business Name:______
Address:______
Owner/Manager/Contact:______
Office Telephone Number:______Private Number:______
Fax Number:______D.I.D. Number:______
(Office Use Only
Email Address:______Website:______
What telephone greeting is to be used by our operators?______
Do you want us to accept collect calls for you? Yes No
Please indicate if you would like us to provide the following information the caller: Business hours? Yes No If yes, please indicate your hours:
Mon.______Tue.______Wed.______Thur.______Fri.______Sat.______Sun.______
Your home number? Yes No If yes, please provide #:______
Your home address? Yes No If yes, please provide:______
______
Please provide detailed information regarding your products or services that you want delivered to your callers:
______
______
______
______
______
(Answers to the following questions will determine how your account and messages are handled)
How will you retrieve your messages? (Please check all that apply to your organization)
Call in periodically Operator call you/page you Both Page & AM Fax Page and Fax Email
Message slips can be faxed or sent to you periodically, please indicate your preferred method and time:
Mailed Faxed Frequency: Daily Weekly Monthly Email None
Do some calls require a higher priority than others? Yes No
If yes, please describe the type of emergency calls and the subsequent instructions. Types of emergencies: ______
Appropriate action:______
Does your business use a revolving schedule of on call personnel? Yes No
If yes, how will you notify us of a new or revised schedule? Mail Fax Email
When? Daily Weekly (Please indicate day) ______Monthly (On request Only)
Please provide a list of your employees in the order they should be notified in case of emergency.
(This list will be used if the on-call staff page is not answered, or if you cannot be reached)
Name Position Home # Pager # Cellular # Email
1.______
2.______
3.______
4.______
5.______
Please provide any additional information that will personalize our handling of your account:
______
______
Between the undersigned (the subscriber) and A.V. Lauttamus Communications, Inc. (“Lauttamus”) d.b.a. Medical Bureau and Telephone Answering Service of Wheeling, and The Ohio Valley Answering Service.
1. This is your authorization to take calls for the undersigned from the date of this agreement, under the service indicated below. A.V. Lauttamus Communications, Inc., cannot and does not assume any responsibility, beyond the return of one month’s basic service charge, for any damages, consequential of otherwise, resulting from a failure by Lauttamus to perform any and all services under this Agreement, including but not limited to a failure to take or relay a message, or to process a call, even where such a failure is the result of Lauttamus’ negligence, misconduct, error, or omission. Accordingly, you and your insurer should be aware that this express disclaimer of liability is an integral part of the contractual relationship between you and Lauttamus. It must be understood and agreed that you will protect, defend, indemnify, and hold Lauttamus harmless from any claim or liability that may be asserted by anyone else, including you and your insurer, in the event or loss, injury, or damage to property or persons including third parties or entities, and persons or entities sought to be protected by this service on an alarm system connected therewith, even if such loss, injury, or damage results or is claimed to have resulted from Lauttamus’ negligence, misconduct, or omission.
2. The subscriber agrees:
A. That the service shall not be used for any illegal purposes, and that Lauttamus shall treat all messages as confidential with the exception that it shall cooperate with all law enforcement agencies, in disclosing whatever information they require, in their performance of their legal duties.
B. To provide a 60 day notice to Lauttamus to terminate services. If a deposit is held it will be credit to the final 30 days, but only when notice is given. Non-payment terminations or disconnects forfeit the deposit in lieu of the required notice.
C. Lauttamus, with notice to subscriber, may terminate service at any time where there is an unpaid balance as of the second month and reserves the right to pursue collection activities.
D. Contract shall expire one year from the date of execution. A 60 day notice must be given prior to contract expiration. If notice is not given, the contract will automatically renew for a period of one year.
E. It is agreed that performance under this agreement shall be deemed to be in Weirton, West Virginia. That in the event of any collection proceedings, subscriber agrees to pay reasonable attorney fees and court costs. That Hancock is the county in which the agreement shall be deemed entered into where performance is to occur. All litigation shall be commenced and prosecuted in Hancock County, West Virginia. The terms of this Agreement shall be governed by the laws of the state of West Virginia.
Date I have read and understand the agreement that accompanies this questionnaire.
______
Client: Date:
______
Lauttamus Representative: Date: