Account Agent Designation

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Account Agent Designation Statement

Questions?

This statement will confirm that the Customer has entered into an agreement with a designated Agent effective as of the date specified below. The Agent will serve as his/her/its Agent for the purpose of arranging and making all decisions regarding service on his/her/its behalf for the Ameren Illinois Account Number(s) listed below. Ameren Illinois will assume this Customer-Agent relationship will remain in force until a Termination of Account Agent Designation Statement is received revoking the designation of this Agent to act on the Customer’s behalf.

The Agent is authorized to make decisions regarding the account(s) noted below. Ameren Illinois may rely on any representation made by Agent regarding this account(s) and need not question the authority of the Agent to act on the Customer’s behalf. Ameren Illinois shall not be liable for any action taken in response to a representation made by Agent. Customer shall be solely liable for any action taken by his/her/its Agent on the Customer’s behalf, including any action taken by the Company at the Agent’s request.

I have read and agree to the above.

Customer Information

* required information

Company Name: *

Contact First Name: *

Contact Last Name: *

E-mail Address: *

name@domain.com

Confirm E-mail Address: *

Phone Number: *

555.123.4567

Account Number: *	Where is this?
Add Another Account Number

Account Number
Your ten-digit account number located on your Ameren bill.

Agent Information

* required information

Company Name: *

Contact First Name: *

Contact Last Name: *

Address: *

Address:

City: *

State: *

ZIP Code: *

E-mail Address: *

name@domain.com

Confirm E-mail Address: *

Phone Number: *

555.123.4567

Effective Agreement Date: *

Send Bills To:*

Customer
Agent

If you are an agent with online access, do you want this account added to your Ameren agent portal? *

Yes
No

What is this?

I affirm that I am the person who prepared this form, or that I have prepared and submitted this form as the duly authorized executor, guardian, authorized officer, or agent of such named person, and that I acknowledge that I have read and understood all of the questions in this application and that all of the information submitted in this application is true and correct to the best of my knowledge, and that all responses to the questions are full and complete, omitting no material information.

Account Number
Your ten-digit account number located on your Ameren bill.

Business Partners Portal

To learn more about Ameren Business Partners Portals, please refer to our Business Partners page.

Tax ID Number

Your Taxpayer Identification Number (TIN) is an identification number issued by the IRS or Social Security Administration. Please enter your 9-digit number with no dashes.

Any person who submits false or inaccurate information as part of this form may be subject to fines and/or punishment pursuant to applicable federal and/or state laws and regulations.