HSA Brochure

Page 1

HSAPolicyNumber (foryourreference)

PROPERTYINFORMATION (REQUIRED)

PropertyAddresstobeCovered

CityStateZip

ListingExpirationDate(ifselling)

REALESTATEPROFESSIONALINFORMATION

COOPERATINGREALESTATEASSOCIATE: Buyer Seller

RealEstateCompanyInformation

MainOfficeNumberAgentMobilePhoneNumber

AgentNameAgentEmail

COOPERATINGREALESTATEASSOCIATE: Buyer Seller

MainOfficeNumberAgentMobilePhoneNumber

AgentNameAgentEmail

CLOSINGINFORMATION

Escrow/Closing/TitleCompany

MainOfficePhoneNumberFaxPhoneNumber

ESTIMATEDCLOSINGDATE ClosingNumber

ClosingRepresentativeNameEmailAddress

SELLERINFORMATION

FirstNameLastName

PhoneNumberEmailAddress

MailingAddress-Onlyifdifferentfromcoveredproperty

BUYERINFORMATION

FirstName

LastName

PhoneNumberEmailAddress

MailingAddress-Onlyifdifferentfromcoveredproperty

*Iftheupgradepackagehasbeenselectedandthepropertyisamultiplefamily dwelling,theupgrademustbepurchasedforeachunit.

**Notavailableonmulti-yearproperties.

ᵻNotavailableforcondos/townhomes/mobilehomes.

ⱡAddtaxwhererequiredbylaw.Toobtainexacttaxamountspleasecall 800.367.1448.Finaltaxwillbecalculatedontheorderconfirmation.

EASYENROLLMENTOPTIONS

Online:own.onlinehsa.com

Phone:800.367.1448

MailWITHpayment:HSA,P.O.Box650993 ● Dallas,TX75265-0993

MailWITHOUTpayment:HSA,1524USHWY30E ● Carroll,IA51401

SELECTCOVERAGEDESIRED:$100TradeCallFee COVERAGE: BuyerandSellerCoverage BuyerCoverageOnly (SellerCoverageisnotavailableformulti-familydwellings.) NEWCONSTRUCTION

Call800.367.1448forcondonewconstruction,buyercondo/townhomemobilehomes,duplex,triplex,fourplexandcoveragepricing.

Somelimitationsandgeneralexclusionsapplytocovered items.Pleasereadthesamplecontractsectionofthisbrochurefordetails.

Byapplicationforthiscontract,sellerand/orbuyerrepresentthat, tothebestoftheirknowledge,allComponentPartsareinProperWorkingOrderonthedate ofapplicationforthiscoverage.ProperWorkingOrdermeansthattheComponentPartsare functioningasintendedandexpectedforitsage,andwithinthesafetystandardsasestablishedby thesystemmanufacturer.Further,sellerand/orbuyeragreethatfailuretonotifyHomeSecurityof America,Inc.(“HSA”)priortorepairorreplacementofanyComponentPartmayresultinarefusal ofcoverageonthatComponentPart.

HSAdisclosestothepurchaserofthishomewarranty,andthepurchaserconsentsand acknowledgesbyhis/hersignaturethattherealestatebrokerageassociatedwiththeinitiatingreal estateassociatemayreceiveaminimalfeeforservicesrenderedinmarketingoradministeringthe saleofthishomewarrantyplan.

CoverageDesired: SellerandBuyerCoverageBuyerCoverage

Applicantsignature Date

WAIVER: Purchaseofthishomewarrantyisnotmandatory.HSAhomewarrantyisnottheonly homewarrantyavailable.Nootherservicesarecontingentuponthepurchaseofahomewarranty. IhavereviewedtheHomeWarrantyProtectionplanandherebydeclinecoverage.Iagreeto holdtherealestatebrokerandrealestateprofessionalharmlessintheeventofasubsequent mechanicalfailurewhichotherwisewouldhavebeencoveredunderthewarrantyplan.

SingleFamily (SFH) $550 $1,100 $675 Condo/Townhome/mobilehome $510 $1,020 $625 Duplex $795 Triplex $1,190 Fourplex $1,590
Centralheat, airconditioning/heatpump $50 $50
1YEAR 2YEAR (YEARS2-4) (Coveragebeginsoneyearafterclosing)
Call800.367.1448foroptionalcoveragepricing. SELLERHVACOPTION
(OnlyavailablewhenBuyerandSellerCoverage ispurchased.) BUYEROPTIONS
SFH SFH SFHNEWCONSTRUCTION BUYER7STARUPGRADE* $149 $298 $149 ElectronicsProtectionPlan** $216 Waterwellpump/septicsystemᵻ $100 $200 $125 Watersoftener $40 $80 $50 Electronicaircleaner $40 $80 $50 Clotheswasheranddryer $70 $140 $85 Homefreezer $40 $80 $50 Hottub $125 $250 $155 Swimmingpoolᵻ $150 $300 $185 Pool/hottubcombination (mustsharecommonmechanicals)ᵻ $175 $350 $215 TOTAL Subtotal $ SalesTaxⱡ$ Total(paymentdueatclosing)$ Pleasemailpaymentinwithapplication. CoverageLimitations:
ACKNOWLEDGEMENT:
Signature Date ©2022HomeSecurityofAmerica,Inc.Allrightsreserved. HSNA22 -NC-BHHSCarolinas Phone: Fax: ProducedwithLoneWolfTransactions(zipFormEdition)717NHarwoodSt,Suite2200,Dallas,TX75201 www.lwolf.com BHHS Carolinas Realty, 110 Oakwood Drive, Suite 110 Winston-Salem, NC 27103 (336) 724-2000 BHHS Carolinas

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