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Special Basic Package*
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Additional Options Available
2nd Air Conditioner
2nd Refrigerator/ Ice maker / Ice Water Dispenser
Door Seals & Gaskets
Double Oven
Freezer
A/C / Heat Emergency Service
Plumbing and Electrical Repair Only
Pool Motor - repair only
Printed Circuit Boards & Touch Pads
2nd Water Heater ( Up to 50 gals)
Sub-Total:
Tax (7.00%):
Grand Total:
Property To Be Covered
Seller`s Name*

Seller`s Email

Address 1*

Suite or Apt #

City*

State*

Zip Code*

Seller`s Phone Number

Age of Home

Salesperson Name

Buyer Information
Buyer`s Name

Buyer`s Phone Number

Buyer`s email

Buyer`s Address

Buyer`s City

Buyer State

Buyer`s Zip

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*

 

3.5 % Credit Card Payment
I understand a 3.5% convenience fee will be added for Credit Card payments.
Routing Number

enter your bank routing number
Bank Account #

Enter your bank account number
Verify Routing #

reenter yourrouting number
Verify Bank Account #

reenter your bank account #
Please make mail your check to:
Broward Factory Service
3500 N. 28th Terrace
Hollywood, FL 33020
Card Brand*

Credit Card #

Expiration Date

CVV#


Billing Address

Address Line 2

Billing City

Billing State

Billing Zip

Confirmations - Email confirmations will be sent to email address entered below
Confirmation #

Email address*

Send confirmation to
 
The rate charged for the service agreement is not subject to regulation by the Office of Insurance Regulation.
Florida - A/C CA-C056778 Florida - A/C CA-C057400 Florida- Plumbing CFC1430745
Florida -Electrical ES-0000336 - Florida Electrical EC13007734
Nevada A/C 0040504, 0081113 Nevada Water Heater 0046467 Nevada Plumbing 0081114
Texas Plumbing M-44053 Texas A/C TACLB20853E, TACLB33262E, TACLB98475E
Arizona A/C 280095,279402 Arizona Plumbing 289307
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