BFS Arizona and Nevada Order Form (buyers only)

BFS Arizona and Nevada Order Form (buyers only)
How did you hear about BFS Home Warranty?
 Mailer  Realtor  Just surfed in  Friend or Neighbor  Other 
E-Mail
Important: Enter a valid e-mail address. Receipts will be sent to this address.
*E-Mail:  
Real Estate Transaction (Buyer Coverage only)
Realty Office  
Agent`s Name  
Address Line 1   Realty Office Address
Address Line 2:   Apt. or Suite No.
City:  
State:  
Zip Code:  
Phone:   Input as: 000-000-0000
Fax:   Input as: 000-000-0000
Closing Company  
Closing Agent  
Closing Date   
Title Company  
Title Co. Phone Number:   Input as: 000-000-0000
Title Co. Fax:   Input as: 000-000-0000
YOUR BASIC COVERAGE INCLUDES: 2 AC Units, Heating, Electric, Trash Compactor,
Dishwasher, Disposal, Oven/Range, Built-in Microwave, Water Heater, and Plumbing.
*Home Warranty Select One:  
Available Options
NO DEDUCTIBLE    No Deductible Option - Unlimited Number of Service Calls $150.00  
13 SEER AC option  
Add Air Conditioner    Additional 3rd Air Conditioner $99.00  
Add Pool/Spa    Pool / Spa Coverage $160.00  
Circuit/Electronic Boards    Circuit/Electronic Boards Coverage $75.00  
Add Refrigerator/Ice Maker    Refrigerator/Ice Maker/Ice and Water Dispenser $50.00  
Add Washer/Dryer    Washer/ Dryer Coverage $80.00  
Add Garage Door Opener    Garage Door Opener Coverage $25.00  
Add Stoppage    Stoppage Coverage $25.00  
Coverage Total:  
Property to be covered
*First Name:   First name of homeowner
*Last Name:   Last name of homeowner
*Property Address Line 1:   Address of property covered
Property Address Line 2:   Apt. or Suite No.
*City:  
*State:  
*Zip Code:  
Phone:  
Customer`s Billing Information
*First Name:   Same name as on your card
*Last Name:  
*Customer`s Address:   Where your statement is mailed
Address Line 2:   Apt. or Suite No.
*City:  
*State:  
*Zip Code:  
Phone:  
Homeowner`s Credit/Debit Card Information (Optional for real estate transaction)
or mail your check to: B.F.S. • ATTN. Contract Department • 3500 N 28 Terrace • Hollywood, FL 33020
Name on Credit Card  
Card Number:   No dashes or spaces please
Expiration Month:   From your card
Expiration Year:   From your card
Card Brand:  
CVV2:   Card Security Code
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