|
|
| Applicant Information |
| |
Mr. |
| |
Mrs. |
| First Name: |
|
| Last Name: |
|
| Cell Phone: |
|
| |
Best Contact? |
| |
I am 62 years or older |
|
|
| Billing Address: |
|
| Unit #: |
|
| City: |
|
| Zip Code: |
(5 digits) |
| State: |
|
|
|
|
|
| Co-Applicant Information |
| |
Co Mr. |
| |
Co Mrs. |
| Co First Name |
|
| Co Last Name: |
|
| Co Cell Phone: |
|
| |
Best Contact? |
| Contact Information |
| Daytime Phone: |
|
| |
Best Contact? |
| Evening Phone: |
|
| |
Best Contact? |
| Email: |
|
| |
Best Contact? |
| Financial Information |
| Select Payment Option: |
|
| Payment Method: |
|
| Note: |
All billing and contract selections are confirmed by Phone or in Person to assure the highest accuracy and customer satisfaction. All payment options except one time single billing option will be recurring credit card charge. |
| Property Information |
|
If same as Billing Address please type "same" in Service Address box |
| Service Address: |
|
| Service Address Unit#: |
|
| Service Address City: |
|
| Service Zip Code: |
(5 digits) |
|
|
| Property Type: |
|
| Occupancy: |
|
| Number of A/C's |
Annual Pricing Single Contract Multiple Contract |
| |
(USD) Regular Senior Regular Senior |
| Yes |
Central A/C System $122.00 $109.80 $109.80 $98.82
Repair Contract: |
| A/C Age: |
|
| Yes |
Variable Speed Condenser $24.00 $21.60 $21.60 $19.44 Fan Motor Repair
(inc. control module and circuit boards) |
| Yes |
Compressor Repair $30.00 $27.00 $27.00 $24.30 Agreement |
| |
Dual Compressor $15.00 $13.50 $13.50 $12.15 |
| Yes |
Split System Coil Repair $42.00 $37.80 $37.80 $34.02 |
| Yes |
Package Unit Coil Repair $45.00 $40.50 $40.50 $36.45 |
| Yes |
Central A/C System $115.00 $103.50 $103.50 $93.15 Maintenance: |
|
Number of Air Conditioning systems |
| Yes |
Heating System Repair Contract $85.00 $76.50 $76.50 $68.85
(includes Heat Pump) |
| Heating Unit Age: |
|
| Yes |
Variable Speed Blower $24.00 $21.60 $21.60 $19.44 Motor Repair
(inc. control module and circuit boards) |
| Yes |
Heating System Maintenance: $115.00 $103.50 $103.50 $93.15 |
|
Number of Heating system: |
| Yes |
Water Heater Repair Contract: $30.00 $27.00 $27.00 $24.30 |
| Water Heater Age: |
|
| Yes |
Water Heater Maintenance $45.00 $40.50 $40.50 $36.45
(only with and performed
during heating maintenance visit) |
| Number of Water Heaters |
|
| Yes |
Internal Gas Piping Repair $24.00 $21.60 $21.60 $19.44 |
| Piping System Age: |
|
| Number of Piping Systems: |
|
|
|
|
|
|
Above prices exclude sales tax. Your first billing will include total sales tax for the contract. |
| Taxing Authority: |
|
| Other Information |
|
|
|
I authorize Comfort Dynamics LLC to verify
my equipment condition and affirm all information above to be correct. I have read and agree to terms and conditions of agreements I have selected. |
