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Special Basic Package*
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Additional Options Available
A/C Over 3 tons/ per ton
Plumbing and Electrical Repair Only
Pool Pump (Motor Only )
Printed Circuit Boards
Second Air Conditioner
Water Heater Over 50 Gal.
Second Refrigerator - Service Only
Freezer --Service Only
Sub-Total:
Tax (7.00%):
Grand Total:
* Tax is estimated and will be adjusted as necessary
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
New Owner`s Name

New Owners Phone Number

New Owner`s email

Real Estate Agent and Real Estate Office Information
Agent Name

Agent`s Phone #

Agent`s Email*

Real Estate Company

Real Estate Phone

Payment Information
Payment Method*

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

Credit Card #

Expiration Date

CVV#


Billing Address

Address Line 2

Billing City

Billing State

Billing Zip

Confirmations - Email confirmations will be sent from Dan Kapellen
Confirmation #

Send Confirmation Email to:*

 
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
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