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Special Basic Package*
Choose Package
Realty Special Gold Package - $449.00
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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*
Choose a State
Arizona
Florida
Nevada
Texas
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*
Choose a Payment Method
I want to Mail a Check
I want to pay by Credit Card
Please make mail your check to:
Broward Factory Service
2071 Emerson Street Unit 16
Jacksonville, Fl 32207
Card Brand*
Choose a Card
American Express
Master Card
Visa
Credit Card #
Expiration Date
CVV#
Billing Same as Covered Property Address?
Yes
No
Billing Address
Address Line 2
Billing City
Billing State
Choose a Billing State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Billing Zip
Confirmations - Email confirmations will be sent from Dan Kapellen
Confirmation #
Send Confirmation Email to:*
Terms and Conditions
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
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