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Special Basic Package*
Additional Options Available
  A/C Over 3 tons/ per ton
  Plumbing and Electrical Repair Only
  Pool Pump only
  Printed Circuit Boards
  Second Air Conditioner
  Water Heater Over 50 Gal.
  Second Refrigerator - SILVER ONLY
Tax (7.00%):
Grand Total:
Property To Be Covered
Seller`s Name*

Seller`s Email

Address 1*

Suite or Apt #



Zip Code*

Seller`s Phone Number

Age of Home

Salesperson Name

Buyer Information
New Owner`s Name

New Owners Phone Number

New Owner`s email

Payment Information
Payment Method*

Please make mail your check to:
Broward Factory Service
15980 S. US Highway 441
Summerfield, FL 34491
Card Brand*

Credit Card #

Expiration Date


Billing Address

Address Line 2

Billing City

Billing State

Billing Zip

Confirmations - Email confirmations will be sent from Connley Davidson.
Confirmation #

BFS SalesPerson Email*

The rate charged for the service agreement is not subject to regulation by the Office of Insurance Regulation.

License Numbers: CA-C057400 CF-C056867 ES-0000336