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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
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 2

Closing Company
Closing Company Name

Escrow Officer

Phone Number


Closing Date

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.

A/C CA-C056774 Florida - Plumbing CF-C056867 Florida - A/C CA-C057400
Florida -Electrical ES-0000336 Florida - A/C CA-C056778 - Florida Electrical EC13007734