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Additional Options Available
A/C Check Up (one time)
Second Air Conditioner
Second Refrigerator
Freezer
Second Air Conditioner
Second Refrigerator
Freezer
Plumbing and Electrical (Repair Only)
Printed Circuit Boards
Sub-Total:
Tax * local county/city tax may apply (7.00%):
Grand Total:
Property To Be Covered
Name*

Email

Address 1*

Suite or Apt #

City*

State*

Zip Code*

Phone Number

Age of Home

Salesperson Name

Seller/Buyer Information
Buyer`s Name

Buyer`s Phone Number

Buyer`s email

Seller`s Name

Seller`s Phone Number

Seller`s email

Agent`s Information
Agent`s Name

Agent`s Phone

Agent`s Email

Real Estate Company

Address

Address 2

Closing Company
Closing Company Name

Escrow Officer

Phone Number

Email

Closing Date

Payment Information
Payment Method*

Please make mail your check to:
Broward Factory Service
6240 Arc Way
Ft Myers, FL 33966
Full Name on Credit Card

Card Brand*

Credit Card #

Expiration Date

CVV#


Billing Address

Address Line 2

Billing City

Billing State

Billing Zip

Confirmations - Email
Confirmation #

Email Address for Confirmation*

 
The rate charged for the service agreement is not subject to regulation by the Office of Insurance Regulation.
A/C CA-C056774 Florida - Plumbing CFC1430745 Florida - A/C CA-C057400
Florida -Electrical ES-0000336 Florida - A/C CA-C056778 - Florida Electrical EC13007734





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