| WelGard | Well Water Warranty- MD/PA/DE/VA - Welgard

Are there any obstructions to the well?(Required)

Yes

Please Explain(Required)

Any well problems in the past 12 months?(Required)

Yes

Please Explain(Required)

Is this a new / replacement well?(Required)

Yes

Unknown

Please Explain(Required)

Have you ever run out of water?(Required)

Yes

Please Explain(Required)

Any loss / low / changing water pressure in the past year?(Required)

Yes

Please describe(Required)

Is the well over 500' deep (subject to surcharge)?(Required)

Yes

Unknown

Have you had the well inspected in the past 90 days?(Required)

Yes

One can be scheduled ($299.00 cost) - 1st choice preferred date

One can be scheduled - 2nd choice preferred date

WelGard Protection Plan Membership

Includes the repair or replacement of (a.) a well yielding less than 1 gallon per minute (drilling a new well), (b.) all well components up to and including the pressure tank, including replacement of a defective well cap, water and electric line from the well to the house, well pump and connections, valves, fittings and adapters as determined by Well Guardian Corporation (WGC).At the discretion and direction of WGC, this protection may not be effective until after the successful completion of well testing and inspection, including a visual inspection of the well system components described in (b.) above, testing of the functioning of the pump and tank, and a flow/yield test. If selected (optionally by Member), WGC will arrange for water safety testing including bacterial analysis, Nitrates, pH, and turbidity. Call-in orders for these services are accepted and scheduled promptly based on options selected. Surcharges for deep well and Constant Pressure Equipment will apply retroactively to the start date if, in servicing your well, WGC determines such charges are applicable.

Certification

Member certifies that the above information is correct to the best of my/our knowledge, that the subject well is for residential use only, is free of defects upon sign-up and is in good working order. Defects later found to exist as of the effective date of this Agreement will not be included in benefits provided. Member may cancel the Agreement during the initial 30 day recission period, and Member will receive a full refund of fees paid, excluding all costs incurred. Member understands that WGC will not be responsible for normal wear and tear of equipment, including well or equipment failure, that may occur during testing completed in order to accept this Application. Member has read and agrees with all of the description of Services, Terms, Conditions and Limitations at www.WellGuardian.us/Terms, as revised from time to time. WGC agrees to automatically renew this Membership, only with Member full and timely payment in amounts billed by WGC. This Agreement is not insurance and is not subject to any State insurance law. Obligations to provide benefits are backed by the full faith and credit of WGC.

Enter your full name to acknowledge you have read above(Required)

Street Address:(Required)

Phone(Required)

Email(Required)

Member Disclosure Form

WelGard Protection Plan Membership

Certification

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