| Submission Options |
You can print this form and mail to:
US Home Protective Association Inc.
P.O. Box 273
New Bremen, OH 45869
or
You can print this form and fax to 866-922-5182
or
Email to us by clicking on Submit at the bottom of this form
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| Your Email Address: |
Please verify your email address
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| Seller Information |
| Name: |
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| Address: |
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| City: |
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| County: |
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| State: |
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| Zip: |
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| Phone: |
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| Real Estate Company: |
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| Real Estate Company Phone: |
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| Agent: |
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| Listing Date: |
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| Listing Expiration Date: |
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| Buyer Information |
| Name: |
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| Address: |
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| City: |
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| County: |
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| State: |
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| Zip: |
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| Phone: |
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| Real Estate Company: |
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| Real Estate Company Phone: |
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| Agent: |
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| Closing Date: |
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| Closing Contract Number (If Known): |
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| Closing Agent: |
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| Property Information |
| Address of Property: |
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| City: |
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| State: |
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| Buyer_Seller/Buyer Information |
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I request home warranty coverage for both the home seller and the home buyer.
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I request home warranty coverage for the home buyer.
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Construction Type: |
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| Estimated Above Ground Square Footage: |
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| Year of Construction: |
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| Number of Levels Above Ground: |
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| Appliances not staying with home |
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Refrigerator
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Washer
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Dryer
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Stove
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| Other |
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AGREEMENT
I hereby apply to U.S.Home Protective Association, Inc. for the Limited Home Service Contract described herein.
I understand that by signing below, I am representing that the mechanical and structural items covered under this
contract are in good operating condition (except any specifically noted as excluded on this application) on this date
and will continue to be in good operating condition on the transfer date of coverage to the buyer.
I also understand that by my signature below, I agree to pay all fees due on the date that legal title is transferred. My election to purchase this contract is binding
and may not be cancelled or rescinded. If I fail to pay the specified fees on the date of closing, I shall be liable for all attorney fees and court costs incurred
by U.S. Home Protective Association, Inc. in the collection of same.
Ohio Residents Only:
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insured,submits an application
or files a claim containing a false or deceptive state, is guilty of insurance fraud.
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Systems or appliances that are not currently in good operating condition are the following:
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Seller(s) Signature: ________________________________________________________________
Date: ______________________
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Buyers(s) Name (please type or print clearly.):
________________________________________________________________
Buyers(s) Signature:
________________________________________________________________
Date: ______________________
Closing Date: ______________________
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In lieu of signature when emailing this form, the following is required:
Seller Social Security Number:
Seller Date of Birth:
Buyers Social Security Number:
Date of Birth:
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