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Offered Through:

SPONSOR INFORMATION

APPLICATION

ResponseNow Anywhere

Sponsor Name: ______________________


10878 Westheimer Rd., Suite #191, Houston, TX 77042
Phone: 1.866.365.5829 Fax: 1.866.837.4556
Plan Information (Please Choose Service Level)

IMA#:_____________________________

Monthly Plan

Date:_________________________________

Quarterly Plan

Annual Plan

$39.95 Monthly

$37.95 Monthly/$113.85 Per Quarter

$34.95 Monthly/$419.40 Per Year

One-Time Activation Fee: $35.00 Shipping Cost: $14.95

One-Time Activation Fee: $35.00 Shipping Cost: Free

One-Time Activation Fee: $35.00 Shipping Cost: Free

Lockbox Option

Lockbox Option

$3.95 Monthly

$3.95 Monthly

Lockbox Option
Included

Total Amount Due:

Total Amount Due:

Total Amount Due:

$89.90
($93.85 with Lockbox Option)

$148.85
($160.70 with Lockbox Option)

$454.40

Subscriber/Customer Information (Please Print Clearly)


Last Name:____________________________ First Name: ________________________________ M.I.:________________D.O.B:___________________
Gender:_____________________________________________________ Language:______________________________________________________
Billing Address:______________________________________________________________________________________Apt #:___________________
City:_______________________________________________________ State: __________________________________Zip: ____________________
Shipping and Billing Address are Same:

Yes

No, please fill in Shipping Address

Shipping Address:____________________________________________________________________________________Apt #:___________________


City:_______________________________________________________ State: __________________________________Zip: ____________________
E-mail:_____________________________________________________ Home Phone #:__________________________________________________
Cell Phone #:_________________________________________________ Work Phone #:___________________________________________________
Special Instructions:__________________________________________________________________________________________________________
Billing Information (Billed By ResponseNow Medical Alert Systems)

Monthly Plan

Quarterly Plan

$89.90
$93.85 with Lockbox Option)

Bank Draft or Debit: (check only one)

Checking

$148.85
$160.70 with Lockbox Option)

Annual Plan
$454.40

Savings

Name of Account Holder:_____________________________________________ Bank Name:________________________________________________


Bank Transit #:_____________________________________________________ Bank Account #:_____________________________________________
Credit Card: (check only one)

VISA

American Express

Discover

MasterCard

Name of Account Holder:______________________________________________________________________________________________________


Account #:_________________________________________________________ Expiration Date:________________________ CVV2 #:______________
(The CVV2 # is the last 3 digits next to the signature line on the back of your credit card; or the 4 digits after your account # for American Express)
I have read the Service Agreement terms and conditions, at the end of this application, and authorize ResponseNow Medical Alert Systems or its designated attorney-infact to electronically draft my account or bill my credit card indicated on this application for my one-time initial application fee and my plan monthly/quarterly/annual fees.
Check this box if you are paying for this plan and are not the Subscriber/Customer.
X_________________________________________________________________________________________ Date: __________________________
Signature of the Depositor or Credit Card Holder (Must be signed by payor if subscriber/customer is not paying the plan fees)

AWIS272_ResponseNowAnywhere_Application | Rev:07.23.2014

Responder Information (Please Print Clearly)


Responder #1 First Name: _____________________________ Last Name:______________________________________________
E-mail:_________________________________________________________ Home/Cell Phone #:___________________________________________________
Responder

Call Before Dispatch

Notify of Transport

Has Keys

Responder #2 First Name: _____________________________ Last Name:______________________________________________


E-mail:_________________________________________________________ Home/Cell Phone #:___________________________________________________
Responder

Call Before Dispatch

Notify of Transport

Has Keys

Responder #3 First Name: _____________________________ Last Name:______________________________________________


E-mail:_________________________________________________________ Home/Cell Phone #:___________________________________________________
Responder

Call Before Dispatch

Notify of Transport

Has Keys

Responder #4 First Name: _____________________________ Last Name:______________________________________________


E-mail:_________________________________________________________ Home/Cell Phone #:___________________________________________________
Responder

Call Before Dispatch

Notify of Transport

Has Keys

RESPONDER
A Responder is able to physically respond to the customer during an alarm activation. Typically
only recommended for a neighbor or someone who lives nearby.

CALL BEFORE DISPATCH


This person should be called before emergency personnel (ahead of EMS) in the event of an alarm
press.

NOTIFY OF TRANSPORT
Whether the person listed should notified in the event a customer is transported from the home
during an emergency.

HAS KEYS
Whether or not the listed person has keys to the customers home.

Agreement of Terms & Conditions (Please Print Clearly)


I understand that I have purchased ResponseNow Anywhere from a, IMA#u .
I have read and understand the Service Agreement Terms & Conditions set forth below.
X _________________________________________________________________________________________ Date: __________________________
Signature
Service Agreement Terms & Conditions
1.

PARTIES AND SERVICES: The person named as Subscriber and any person
ordering/paying for Services (Payer) or using them (User) (collectively referred
to as Subscriber) hereby contract with ResponseNow Medical Alert Systems
(ResponseNow) for ResponseNow medical alert system monitoring service (Service).
Unless the context otherwise requires, the term Subscriber as used herein refers all
User(s) and Payer(s), and any of them individually. The obligations of Subscriber are
joint and several, meaning that Payer(s) and User(s) are equally, and each individually,
responsible for the obligations of the Subscriber under this Agreement.
The Service includes ResponseNow equipment and monitoring. Equipment means a
ResponseNow Anywhere personal help button (Equipment). Monitoring is provided
through an authorized ResponseNow monitoring center. During the initial and any
renewal term of this Agreement, Equipment remains the property of ResponseNow
and must be returned to ResponseNow at the end of this Agreement as set forth
in Paragraph 2 below. If Subscriber fails to return the Equipment as set forth in
Paragraph 2, Subscriber will be fully liable for the value of the Equipment, which
Subscriber agrees is $250.

ResponseNow may in its sole and absolute discretion and without liability, refrain
from alerting the Responders or advise the Responders of the receipt of oral advice to
disregard the alarm signal.
SUBSCRIBER AGREES THAT ATTEMPTING TO NOTIFY BY THE PHONE DESIGNATED
RESPONDERS IS RESPONSENOWS ONLY DUTY. Subscriber understands and
agrees that: (a) ResponseNow is not responsible for the promptness, sufficiency or
adequacy of the action of any Responder or any third party acting for Responder; (b)
ResponseNow in no way represents or guarantees that Responders can be contacted,
can or will respond, or that any response will be safe or effective; (c) the Responders
have been designated by him or her and are not agents or other representatives of
ResponseNow; and (d) ResponseNow will not send any of its personnel to Subscribers
premises in response to any emergency signal.
2.

TERM & TERMINATION: This Agreement starts when the Agreement is acknowledged
online by the Subscriber or Web-Buyer or when the equipment is activated by the
Subscriber. The original term of this Agreement is the service plan selected above
and will renew for the same consecutive billing cycle thereafter unless terminated
as set forth below. The Agreement will remain in effect for a minimum of THREE (3)
months. After three (3) months it may be terminated by either party by sending the
other party thirty (30) days written notice. ResponseNow may terminate this Agreement
and Services hereunder at any time for non-payment of fees or abuse of the service.
Upon termination, Subscriber will return Equipment to ResponseNow by 1. mailing or
shipping the Equipment to ResponseNow at Subscribers expense (a pre-addressed
return envelope has been provided concurrently with Equipment), or 2. Telephoning
ResponseNow and arranging for pick-up. If Subscriber fails to return Equipment within
thirty (30) days of termination, Subscriber agrees to pay ResponseNow the value of
Equipment which is $250 and which Subscriber hereby authorizes ResponseNow to bill
to Subscribers credit card or bank account or otherwise collect.

3.

BINDING AGREEMENT: This Agreement is binding on Subscriber, Subscribers heirs,


executors and administrators. Subscriber, including each User and Payer, each shall be
jointly and severally liable to satisfy the Subscribers obligation under this Agreement

The Service includes receipt, analysis and response to alarm signals from Equipment.
Upon receipt of a signal, ResponseNow: (a) will make reasonable effort to promptly
contact Subscriber, and (b) if ResponseNow deems necessary in its reasonable
judgment, notify: (i) persons and entities designated by Subscriber as Responders in
the new order information sheet, in the order designated by Subscriber, or (ii) police,
fire or ambulance designated by Subscriber.
Subscriber agrees that ResponseNow may rely absolutely on the statements of
Subscriber, Responders, or any person who says that they are acting on behalf of a
Responder or Subscriber, with respect to the location and condition of Subscriber.
Subscriber agrees that ResponseNow in its sole and absolute discretion and without
any liability: (a) may contact or attempt to contact the Premises as frequently as
ResponseNow deems appropriate to verify the need to alert Responders; and (b) after
receiving oral advice from anyone at the premises to disregard the alarm signal and

AWIS272_ResponseNowAnywhere_Application | Rev:07.23.2014

and are each bound by its terms, including Paragraphs 14 and 15. By accepting
these terms and conditions, Subscriber, including any User and Payer, each represent
that they are agents of each other. and (a) Subscriber represents and warrants to
ResponseNow that Subscriber has the full power and authority to bind any Payer and
User to these terms and conditions; and (b) each Payer represents and warrants to
ResponseNow that Payer has the full power and authority to bind Subscriber and any
User to these terms and conditions.
4.

5.

SUBSCRIBER DUTIES: In addition to other responsibilities set forth elsewhere in this


Agreement, Subscriber must:
A.

Provide and be responsible for suitable electrical outlet for periodic charging
of the Equipment.

B.

Select and give accurate information as to all Responders. Subscriber represents


that personal Responders have agreed to act as responders;

C.

Provide Responders with access to Subscribers house;

D.

Not alter or attempt repairs to Equipment;

E.

Activate and use the Equipment according to ResponseNows written


requirements found in the user guide as provided with the delivery of Equipment;

F.

Promptly inform ResponseNow of any changes to the information provided in,


or in connection with, this Agreement. All changes are the sole responsibility of
Subscriber and shall become effective at the time of delivery to ResponseNow;

G.

Test equipment at least every month with the personal help button following
recommended testing established by ResponseNow;

H.

Pay any fine resulting from any false alarm.

FEES: Subscriber agrees to pay the periodic fees (monthly, quarterly, or annual)
associated with the Agreement along with any applicable sales tax or for any
additional ResponseNow services later agreed to by the parties. Payments are due in
advance of the period being billed on the anniversary of the activation date. The initial
payment is due upon activation or online transaction completion and is in accordance
with the payment plan selected (monthly, quarterly or annual).
A.

Late Fees: If a payment is not made for any reason (including an expired credit
card or insufficient funds in a checking account), you agree to pay us a late
fee for the administrative cost we incur in the amount of $35.00 for each late
payment, or such lower amount as my be permitted or authorized by law.

Incident), ResponseNow may notify any or all of the parties listed in this Paragraph.
Further, Subscriber releases ResponseNow from all liability, which may arise out of
ResponseNows disclosure of information in this Agreement or about any Incident to
the parties listed in this Paragraph. Subscriber acknowledges that all communications
between Subscriber and ResponseNow Monitoring Center may be recorded and
Subscriber consents tosuch recording.
9.

FALSE ALARMS OR ABUSE OF SERVICE: Subscriber agrees to reimburse


ResponseNow for any fees assessed against ResponseNow as a result of false alarms
originating from Subscribers premises.

10. FORCED ENTRY; MEDICAL EXPENSES: Subscriber agrees that if ANY ALARM
SIGNAL is received by ResponseNow and a Responder is sent to Subscribers home
and Subscriber cannot let Responder into the locked home and Responder does
not have a key that THE SUBSCRIBER AUTHORIZED RESPONDER TO BREAK INTO
SUBSCRIBERS HOME. SUBSCRIBER UNDERSTANDS THAT THIS MAY CAUSE DAMAGE
TO THE HOME. SUBSCRIBER WAIVES ANY CLAIM AGAINST RESPONSENOW OR ANY
RESPONDER WHICH MAY ARISE AS A RESULT OF FORCED ENTRY INTO THE HOME.
SUBSCRIBER SPECIFICALLY WAIVES ANY CLAIM FOR DAMAGE RESULTING FROM
FORCED ENTRY AFTER AN INACTIVITY ALARM OR NON-RESPONSE TO A REMINDER
SERVICE EVEN IF SUBSCRIBER IS SIMPLY NOT HOME. In in addition, Subscriber
authorizes ResponseNow to notify paramedics and other appropriate emergency
personnel who may provide medical assistance, if necessary. Subscriber hereby
releases ResponseNow from any and all expenses and liability incurred as a result of
such medical services.
11. ATTORNEYS FEES: In connection with any dispute arising under this Agreement, the
prevailing party shall recover from the other party its reasonable costs and necessary
disbursements and attorneys fees incurred in enforcing this Agreement or otherwise
in connection with any lawsuit, arbitration or other legal proceeding related to or
arising under this Agreement.
12. SUSPENSION OR CANCELLATION OF THE AGREEMENT: Subscriber agrees that
ResponseNow may stop or suspend monitoring service for any of the following reasons:
A.

strikes, severe weather, earthquakes or other such events beyond our control
that effect the operations of the Monitoring Center or so severely damage
Subscriber premises that continuing service would be impractical.

B.

There is an interruption or unavailability of the telephone service between the


System and the Monitoring Center.

C.

Subscriber does not pay the service charge due to ResponseNow, after
ResponseNow has given Subscriber five (5) days notice that ResponseNow is
cancelling service because of non-payment.

B.

Refunds: Subscriber will not be entitled upon termination to any refund for
Service that are prepaid for monthly, quarterly, annual or other periods.

C.

Billing information: Subscriber agrees to keep on file with ResponseNow


D. ResponseNow is unable to provide service because of some action or ruling by
acceptable valid bank credit/debit card information, limited to bank cards with
any government authority.
a Visa, MasterCard, American Express or Discover logo. ResponseNow may
terminate this Agreement for non-payment of fees and recover all payments
E. Subscriber becomes a debtor in a bankruptcy proceeding.
due to ResponseNow. In the event it becomes necessary for ResponseNow to
institute legal proceedings to collect payments due under this Subscriber agrees 13. ASSIGNMENT: This Agreement may NOT be assigned by Subscriber except with written
consent of ResponseNow. This Agreement may be assigned by ResponseNow to a
to pay for a full month of service for any month in which the Subscriber has
financial institution or any other personal emergency services provider at any time.
Service.

6.

COMMUNICATION LIMITATIONS: It is understood that the communication of the


device relies upon the availability of cellular service and data which are provided by a
third party that is not controlled by ResponseNow. The ability of the device to accurately
track Subscribers location is dependent the availability of GPS, cellular network and/or
wireless internet coverage depending on Subscribers location. The device will function
only in areas, locations and buildings where such service is available. If such service
is unavailable or unreliable, the device may not accurately reflect your location or, it
may not communicate at all with ResponseNows monitoring center. In such event, the
ResponseNow monitoring center may be unable to communicate your location to a
Responder, and a Responder by not be able to locate you.

7.

INTERRUPTION OF SERVICE: Subscriber acknowledges that the Equipment sends its


signals using cellular services which are wholly beyond the control of ResponseNow.
IN THE EVENT EQUIPMENT IS IN AN AREA WITHOUT CELLULAR SERVICE OR THE
CELLULAR SERVICE FOR THE AREA IS OUT OF ORDER OR DISCONNECTED, THE
EQUIPMENT WILL NOT WORK. ResponseNow does not assume any liability for
interruption of the service due to strikes, riots, sabotage, terrorist activities, floods,
storms, earthquakes, fires, power failure, and interruption of cellular service, acts of
God, or any other cause beyond ResponseNows control including the activities of
Subscriber. RESPONSENOW IS NOT REQUIRED TO SUPPLY THE SERVICE DURING THE
CONTINUATION OF ANY INTERRUPTION OF SERVICE DUE TO ANY SUCH CAUSE.

8.

CONSENT TO DISTRIBUTION OF INFORMATION: Subscriber is providing


ResponseNow with medical information for the purpose of providing the Service.
Subscriber agrees that ResponseNow, Responders and any other party named
in this Agreement may receive all information contained in this Agreement or
otherwise provided by Subscriber to ResponseNow. Subscriber further agrees that
in the event that a Responder or other assistance is sent to Subscribers home (an

14. DISCLAIMER AND LIMITATION OF LIABILITY: Subscriber understands and agrees


that ResponseNow is NOT an insurer and that insurance, if any, covering personal injury
or other personal claims and property loss or damage on Subscribers premises shall
be obtained by Subscriber in such amounts and covering such perils as Subscriber may
determine; that the amounts being paid to ResponseNow are based on the value of the
Service and not on the amount of potential loss, and such amounts are not sufficient to
guarantee that no loss will occur; that ResponseNow is NOT assuming responsibility for
any losses which may occur even if due to ResponseNows negligent performance or
failure to perform any obligation under this Agreement. Subscriber assumes all risk of
loss or damage to premises or the contents thereof, or personal injury.
RESPONSENOW MAKES NO GUARANTEES OR WARRANTIES OF ANY KIND RELATING
TO THE SERVICE AND EXPRESSLY DISCLAIMS ALL WARRANTIES WHETHER
EXPRESS OR IMPLIED, WRITTEN OR ORAL, WITH RESPECT TO THE SERVICE AND
THE EQUIPMENT, INCLUDING ANY WARRANTY OF MERCHANTABILITY OR FITNESS
FOR A PARTICULAR PURPOSE. IF, NOTWITHSTANDING THE OTHER PROVISIONS
OF THIS AGREEMENT, THERE SHOULD ARISE ANY LIABILITY TO RESPONSENOW,
RESONSENOWS MAXIMUM LIABILITY ARISING OUT OF THE PROVISION OF THE
SERVICE, INCLUDING THE EQUIPMENT, OR ITS USE, WHETHER BASED UPON
WARRANTY, CONTRACT, TORT OR OTHERWISE, LIMITED TO THE MAXIMUM SUM
OF $1,000. SINCE IT IS IMPRACTICAL AND EXTREMELY DIFFICULT TO FIX ACTUAL
DAMAGES WHICH MAY ARISE DUE TO A FAILURE OF THE SERVCE, THIS SUM SHALL
BE COMPLETE AND EXCLUSIVE AND SHALL BE PAID AND RECEIVED AS LIQUIDATED
DAMAGES AND NOT AS A PENALTY. IN NO EVENT SHALL RESPONSENOW BE LIABLE
FOR SPECIAL, INCIDENTAL OR CONSEQUENTIAL DAMAGES. SUBSCRIBER MAY
OBTAIN A HIGHER LIMITATION OF LIABILITY FOR AN ADDITIONAL PERIODIC CHARGE.
If Subscriber elects this option, ResponseNow will attach a rider to this Agreement
which will set forth the amount of the limitation of liability and the amount of the
AWIS272_ResponseNowAnywhere_Application | Rev:07.23.2014

additional charge. Agreeing to the higher limitation of liability does not mean that
ResponseNow is an insurer.
15. THIRD PARTY INDEMNIFICATION AND NO SUBROGATION: Subscriber agrees
to indemnity and hold harmless ResponseNow, its employees and agents from and
against all and any claims (including by third parties), lawsuits and losses alleged
to be caused by ResponseNows performance, negligent performance or failure to
perform its obligations under this Agreement. If anyone other than Subscriber asks
ResponseNow to pay for any harm or damages (including property damage, personal
injury or death) connected with or resulting from (i) ResponseNows breach of this
Agreement or a failure of Equipment or Service, (ii) ResponseNows negligence, (iii)
any other improper or careless activity of ResponseNow in providing Equipment or
Service, or (iv) a claim for indemnification or contribution, Subscribers agrees and
will pay to ResponseNow (a) any amount which a court or other tribunal orders
ResponseNow to pay or which ResponseNow reasonably agrees to pay, and (b) the
amount of ResponseNows reasonable attorneys fees and any other losses or costs
that ResponseNow may pay in connection with such third-party claim or dispute.
Unless prohibited by Subscribers property insurance policy or other insurance,
Subscriber agrees to release ResponseNow from any claims of any parties suing
through Subscribers authority or in Subscribers name, such as Subscribers
insurance carriers, and Subscriber agrees to defend ResponseNow against any such
claim. Subscriber will notify Subscribers insurance carrier(s) of this release.
16. LIMITATION ON LAWSUITS; WAIVER OF JURY TRIAL: Both ResponseNow and
Subscriber agree that no lawsuit or any other legal proceeding connected with this
Agreement shall be brought or filed more than one (1) year after the incident giving
rise to the claim occurred. In addition, any such legal proceeding shall not be heard
before a jury. EACH PARTY IRREVOCABLY WAIVES ANY RIGHT TO A JURY TRIAL.
17. ENTIRE AGREEMENT/MODIFICATION/CHOICE OF LAW: This Agreement shall
constitute the entire Agreement between Subscriber and ResponseNow. No person
installing, servicing or otherwise dealing with Equipment is or shall be authorized to
act for or bind ResponseNow. This Agreement supersedes all prior representations,
understandings or agreements between the parties. This Agreement may only be
modified in writing signed by both parties. The parties agree that this Agreement will
be governed by the laws of the State of Oregon.

Offered Through:

American Workers Insurance Services 10878 Westheimer Rd., Suite #191, Houston, TX 77042 Phone: 1.866.365.5829 Fax: 1.866.837.4556
AWIS272_ResponseNowAnywhere_Application | Rev:07.23.2014