ACCOUNT CLOSURE AND
TRANSFER REQUEST
Use this form if you’re a builder closing an energy account held in your name at a property
you’ve been working on, and setting up a new account for the property owner at the same time.
Builders: Please complete sections 1 and 2 then ask the new account holder to complete the other sections and return it to
you. Submit completed forms via Origin Connect Assist at origin.connectassist.com.au or if you’re not a registered Origin
Connect Assist user, you can return forms to [email protected] (don’t forget to scan both sides).
Account holders: Please complete sections 3, 4 and 5 and return this form to your builder.
1. PROPERTY DETAILS
Lot
Level
Unit no.
Street no.
Suburb
Property type
Street
State
Residential
Requested date for disconnection
Postcode
I want to disconnect
Commercial
Electricity
Natural gas
DD MM YYYY
Note: If the date that you request falls on a weekend, public holiday or Friday in South Australia, it’ll be arranged for the next available business day.
2. BUILDER DETAILS (current account holder or authorised representative)
Full name
ABN
Mobile Ph.
Email
I understand that:
I need to give Origin at least 6 business days’ notice to arrange disconnection for the date I’ve requested.
•_ a final read cannot be completed for a date in the past.
•_ disconnection fees may apply as set out in section 5 of this form and these will be included in the final bill sent to me after my account has been closed.
•_ Name of
signatory
Signature
Date
DD MM 20Y Y
3. NEW ACCOUNT HOLDER DETAILS
Company
ABN
(If applicable)
Full name
DOB
Daytime no.
Mobile no.
Email
Driver’s licence
If available
Note: the primary account holder is solely financially liable for the account, even if a secondary account holder is also listed.
Postal details (you must provide a postal address)
Unit no.
Street no.
Street
Suburb
State
Postcode
Please send me my Origin communications (including my bills) by:
Email
Standard post
!
make sure you’ve given us your email address above
Secondary account holder (if applicable)
Full name
DD MM Y Y Y Y
DOB
Daytime no.
Mobile no.
Email
Please add my name to Origin bills
When you nominate a secondary account holder, this person will be able to access all of your Origin accounts.
4. YOUR PRIVACY
You consent to Origin’s collection, use, holding and disclosure of your personal and credit related information in
accordance with our privacy and credit reporting statements, available at originenergy.com.au/privacy. Our credit
reporting statements explain who we disclose credit information to (including service providers overseas) and how this
could affect your creditworthiness, as well as how you can access, correct to complain about it. Please contact us to
request a paper copy.
Product and service offers
We’ll get in touch by phone to let you know about any current offers that may be available for your new energy
plan before we finalise the set-up of your new account. After that, from time to time we’ll let you know about our
great products and offers, even after your agreement ends. But if you don’t want us to, just tick the box below.
Opt me out
5. ACCOUNT HOLDER AGREEMENT
I nominate Origin as the energy retailer for electricity and/or natural gas at my property.
I understand that:
•_ _If Origin can’t reach me, Origin will supply energy on a standing agreement, or if my connection is for natural
gas in New South Wales on the Australian Gas Networks or Central Ranges distribution networks, a regulated
agreement, and send through all the details, including prices.
•_ _I must provide clear and safe access to the meters at this property for my energy connection. If the distributor
or meter reader cannot get to the meters, an additional fee may apply.
•_ A connection fee may apply as set out below. In all states except South Australia and the Australian Capital
Territory, this fee will be included on my first bill from Origin.
Connection/disconnection fees (depending on what state you live in an your distribution area):
State
Electricity
Natural gas
South Australia
Up to around $39
Up to around $12
Australian Capital Territory
Up to around $75
Up to around $16
Victoria
Up to around $61
Up to around $14
Queensland
Up to around $11
Up to around $23
New South Wales
For residential: up to around $92
For business: up to around $194
Up to around $53
Please note these fees are charged by the distributor and passed on by us. These fees are current as at 1 January 2017
and do change from time to time. You can find more details including a breakdown of the fees by state and distributor at
originenergy.com.au/additionalcharges, or for business customers at originenergy.com.au/business/additionalcharges
Energy charges
You can find our energy charges at originenergy.com.au/pricing. The charges that will apply to you will depend on
your metering set up and distributor and won’t be confirmed until after your connection is complete. We will set you up
on the most common rate type for your area and let you know if this is not the rate type that applies to you once your
connection is complete.
Name of
signatory
Signature
Date
DD MM 20Y Y
This section must be signed by the primary account holder.
Reset Form
Other offers
Origin has a number of other offers that may be of interest to you. If you’d like to take up one of these offers
call us on 13 24 61 once your account’s been set up.
originenergy.com.au
Origin Energy Electricity Limited ABN 33 071 052 287 | Origin Energy Retail Ltd ABN 22 078 868 425 | Origin Energy (Vic) Pty Ltd ABN 11 086 013 283
Origin Energy LPG Limited ABN 77 000 508 369 | Sun Retail Pty Ltd ABN 97 078 848 549 | 100 Waymouth St, Adelaide SA 5000
Telephone 13 24 63 | Facsimile 1800 132 463
9096v1.Jan17.All
13 24 61