subject_line
Service Verfication Form
Agent and Agency Information
Real Estate Agent Name
*
Real Estate Agency
Address
*
City
*
State
*
Zip Code
*
Phone
*
Email
*
Date
*
+
Property Information
Contract Number
Street Address
*
City
*
State
*
Zip Code
*
Year Built:
Square Footage:
Water Source
Well
City
Type Of Heating Unit:
Forced Air Furnace
Heat Pump
Geothermal
Boiler
Other
Other
Type of Cooling Unit:
Central A/C
Heat Pump
Mini-Split
PTAC
Wall A/C
Other
Other
Total Number of Heating Units
Total Number of Cooling Units
Check All ADDITIONAL ITEMS Associated with this property:
Water Softener
Well Pump
Pool/Spa
Ice Maker
Jetted Tub
Septic System
Agent Instructions
TO FILE BY FAX/EMAIL/MAIL:
The undersigned hereby confirms that he/she made their best effort to perform services outlined in executed Services Fee Agreement and
hereby submits the information collected as part of those services. The agent is by no means liable for any inaccuracies or inconsistencies
associated with this information as it pertains to the home warranty contract. Submission of the Services Verification Form may result in the
payment of a fee to a broker or sales agent. This form must be submitted within 2 years of the warranty's active date.
Broker/Agent Signature
*
clear
MAIL TO: Home Warranty of the Midwest, Inc.
PO Box 1
Rock Rapids, IA 51246
FAX: 866-977-4949
EMAIL: info@homewarrantyinc.com
Questions? Call 877-977-4949
Powered by