Customer Initiated Disconnect Form

*If you don’t have the required field information please put N/A.*

(*) Required fields


*Are you PORTING your service to another provider? If you are retaining the same service(s) but are going to another provider, please select “Yes”.	Yes No

*Company Name
*Billing Account Number:
Customer Account Number:

Primary Contact Information Please note that you must be authorized on this Level 3 account to submit this form. If you are not listed as an authorized contact the contact on file, must attach a letter of authorization to this form to have you added as an authorized representative.
*Primary Contact Name:
*Primary Contact Phone:
*Primary Contact Email: (Will receive order confirmation) (Separate by semi-colons)
Primary Contact Fax:

*Service ID(s), Circuit ID(s), Telephone Numbers(s) that appears on invoice: (Separate by commas) For Broadwing/Telcove Customers ANIS, Toll Free, or Trunks are acceptable service ID's Please verify that all service ID(s)/Telephone Number(s) fit in the Service ID/Telephone Number field. If not, please attach Service ID(s)/Telephone Number(s) and Service Addresses with an attachment below.


*Are the services you are requesting for disconnect:	Voice Data Both

Requested date of disconnection: The Requested Disco Date must be the same for all circuit IDs that are being submitted on a single form.*	select

*Customer's reason why they are disconnecting their service with Level 3:
General Notes:
*Customer Disconnect Purchase Order Number:
*Service Address (A/Z LOC): If the service is just an ANI or Toll Free, the service A/Z loc is not applicable.
*Trunk Group CLLI:
*Is this a full or partial Disconnect?:	Full Partial

Attachments
If the free form text box limitations have been met above, please attach Service ID(s)/Telephone Number(s) and Service Addresses below. Letter of Authorizations may also be attached. You will need to save the file to a folder on your computer then click the “Browse” button to locate and select the file. Attachments will be emailed back to the primary Contact email address(s)

Attach a File Form...

Please hit SUBMIT only once, a confirmation email will be sent shortly. If you don’t receive a confirmation email please email disconnects@level3.com

Unless otherwise agreed between the parties, the Service identified below for disconnection will be disconnected upon the later of (i) thirty (30) days after Level 3's receipt of this completed Disconnect Request Form or (ii) the requested date of disconnection specified below for Level 3 products and services. If the Service identified below for disconnection is a Genuity IP or Managed Service, the service will be disconnected upon the later of (i) sixty (60) days after Level 3's receipt of this completed Disconnect Request Form or (ii) the requested date of disconnection specified below. If the Service is being disconnected prior to the end of the committed Service Term, early termination charges may apply as agreed between the parties.

Level 3 will use reasonable efforts to rescind a disconnection/cancellation notice. However, once a disconnection/cancellation notice has been processed, Level 3 cannot guarantee that service will be extended beyond the original disconnection/cancellation date. In the event a disconnection/cancellation notice is rescinded, additional charges may apply. All requests to cancel or extend out disconnects must be submitted to disconnects@level3.com

If you have questions on how to complete this form, please contact disconnects@level3.com