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3) Applicant Information: [ ] Buyer [ ] Seller [ ] Homeowner ______________________________________________
Mailing Address (if different from above)
City_____________________________ State______ Zip_______
______________________________________________________
Existing Homeowner Name / Buyer's Name
Tel: ( )_________________ Fax: ( )____________________
_______________________________________________________
Seller's Name
Tel: ( )_________________ Fax: ( )____________________
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Options:
[ ] Swimming Pool
[ ] Spa
[ ] Well Pump
[ ] Septic Tank
[ ] Freestanding Freezer
[ ] Freestanding Icemaker
[ ] Telephone / Alarm Wiring
[ ] Platinum Package Upgrade
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$160
$160
$75
$75
$25
$25
$25
$75 |
Platinum Package Includes: Water Heater Sediment, Garage Door Springs, Hinges, and Transmitters, Removal of Existing Units, Freon Recovery, Code Violations up to $250.
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4) Real Estate Office Information
_____________________________________________________
Initializing Agent E-Mail
_____________________________________________________
Office Name
_____________________________________________________
Office Address
City_____________________________ State______ Zip_______
Office Tel: ( )_______________ Fax: ( )_______________
______________________________________________________
Listing Expiration Date Closing Date
_______________________________________________________
Closing Company's Name
Tel: ( )_________________ Fax: ( )____________________
_______________________________________________________
Officer's Name File Number
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Total Plan Investment
| Total Fee Payable $___________ |
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All Plans have a $50.00 Deductible
*$75.00 Deductible for Roof Leak Coverage |
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| PLEASE DO NOT CALL A CONTRACTOR YOURSELF. YOU WILL NOT BE REIMBURSED FOR ANY WORK PERFORMED WITHOUT ASSURANCE HWC APPROVAL. |
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| IF SERVICE IS REQUIRED: |
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1. SHUT OFF the system or appliance to prevent further damage.
2. Make sure the problem is covered.
3. Is your contract still in effect?
4. Call the Service line telephone number
Phone: 1-866-992-7787
Fax: 1-866-982-7787
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5) NOTICE: Coverage includes only those systems, appliances and components that were in proper operating condition at the contract effective date. AssuranceHWC discloses to the purchaser of this warranty, and the purchaser consents and acknowledges by his/her signature that the employing broker and/or agent may receive a minimal fee for services rendered in marketing or administering the sale of this warranty program.
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[ ] Acceptance of Coverage
Applicant acknowledges that he/she understands the terms and conditions of coverage. Acceptance is acknowledged and completed with remittance of payment to: |
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ASSURANCE HOME WARRANTY CORPORATION
1785 E. SAHARA AVE
SUITE 490-465
LAS VEGAS, NV 89104
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| FAX NEW ORDER TO: 1-866-982-7787 |
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[ ] Waiver of Coverage
I hereby decline to purchase the home warranty plan which
has been presented to me. I agree to hold the Real Estate
Broker/Agent and the Home Inspector harmless in the event of
any subsequent mechanical failure which otherwise would have been covered under this plan.
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ASSURANCE HWC ALSO ACCEPTIBLE FOR PAYMENT
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