Insurance Closing Submission Form

Home Warranty
Member Benefits
About
File a Claim
Contact Us

Home Warranty
Member Benefits
About
File a Claim
Contact Us

Please check your SPAM / JUNK folder for this email submission if you don’t see it in your inbox. Please DO NOT ASSUME the title/escrow company has received it unless you have confirmation from them. We are not responsible for all parties receiving a copy of this submission.

**If you would like anyone to receive a copy of this submission (in PDF format), please include their email address in the appropriate email boxes below.**

View Home Warranty Brochure

"*" indicates required fields

1Step 1 of 3

2Step 2 of 3

3Step 3 of 3

Plan Name

CORE Plan ($695)

PLUS Plan ($795)

Name of Buyer*

First Last

Property To Be Covered

Property To Be Covered*

Property Address Unit # City State ZIP Code

Buyer's Email*

Buyer's Phone Number*

Buyer's Agent*

Agent's Email*

Real Estate Agent or Insurance Agent Name and Office Submitting Warranty?*

Real Estate Agent or Insurance Agents Email*

Title Company*

Estimated Date for Closing*

MM slash DD slash YYYY

To CC Title/Closing Agent, please include email address:

Is Buyer or Seller Purchasing Warranty?

Buyer

Seller

Home Size*

Less than 5,000 Square Feet

5,000 – 5,999 Square Feet

6,000 – 6,999 Square Feet

Greater than 7,000 Square Feet

Promotional Code

How did you hear about HomeMembership?*

Affiliate Code*

What Social Media Platform?

What was the Member's Name?

What was the Sales's Representative's Name?

What was the Insurance Agent's Name?

What was the Real Estate Agent's Name?

Write In

Would you like to add additional coverage?

Select the items below you would like to add to your plan.

Pool (Fresh Water Only) ($600 Total Agg. Limit)*

Pool + $143.05

Yes

Septic ($500 Total Agg. Limit)*

Septic Tank + $117

Yes

Roof ($450 Total Agg. Limit)*

Roof + $104.04 each

Yes

Radon Fan ($400 Total Agg. Limit)*

Radon Fan + $90.96 each

Yes

Deep Freezer ($400 Total Agg. Limit)*

Deep Freezer + $90.96 each

Yes

Water Softener ($400 Total Agg. Limit)*

Water Softener + $90.96 each

Yes

Grinder Pump ($550 Total Agg. Limit)*

Grinder Pump + $125.00 each

Yes

Sump Pump ($550 Total Agg. Limit)*

Sump Pump + $125.00 each

Yes

Main Water Line*

Main Water Line ($1000 Total Agg. Limit)* + $150.00 each

Yes

Electrical / Telecom Line*

Electrical / Telecom Line ($1000 Total Agg. Limit)* + $150.00 each

Yes

Municipal Sewer Line*

Municipal Sewer Line ($1000 Total Agg. Limit)* + $150.00 each

Yes

Termite Damage Repair*

Termite Damage Repair ($1000 Total Agg. Limit)* + $150.00 each

Yes

Maintenance Plan Add-On

Maintenance Plan Add-On + $480

Yes

*No Maintenance Covered

Make sure you are properly covered!

If you have more than one of the units listed below, please add for coverage to apply.

Additional HVAC Units

Additional HVAC Units $156.00 each

Additional Water Heaters

Additional Water Heaters $123.55 each

Additional Refrigerator

Additional Refrigerators $117.00 each

Additional Dishwasher

Additional Dishwashers $84.00 each

Additional Stove

Additional Stoves $84.00 each

Additional Washer

Additional Washers $84.00 each

Additional Dryer

Additional Dryers $84.00 each

Member Recommended Endorsement ($3000 More Coverage)

Member Recommended Endorsement ($3000 More Coverage) + $80.00

Yes

Home Warranty

Price:

Annual Total

Total Yearly Cost

Plan Summary & Total Cost

Paid Yearly

Plan Name:

CORE Plan ($695)

Home Size

Pool (Fresh Water Only) ($600 Total Agg. Limit)

($143.05)

Septic ($500 Total Agg. Limit)

($117.00)

Roof ($450 Total Agg. Limit)

($104.04)

Radon Fan ($400 Total Agg. Limit)

($90.96)

Deep Freezer ($400 Total Agg. Limit)*

($90.96)

Water Softener ($400 Total Agg. Limit)*

($90.96)

Grinder Pump

($125.00)

Sump Pump

($125.00)

Main Water Line

($150.00)

Electrical/Telecom Line

($150.00)

Municipal Sewer Line

($150.00)

Termite Damage Repair

($150.00)

Maintenance Plan Add-On

($480.00)

Additional HVAC Units

0 ($156.00 each)

Additional Water Heaters

0 ($123.55 each)

Additional Refrigerator

0 ($117.00 each)

Additional Dishwasher

0 ($80.04 each)

Additional Stove

0 ($84.00 each)

Additional Washer

0 ($84.00 each)

Additional Dryer

0 ($84.00 each)

Member Recommended Endorsement ($3000 More Coverage)

($80.00)

Annual Subtotal:

Total Yearly Cost

Per Year

a copy of the invoice will be sent to the title company and agent listed on the submission.

Please make check payable to:
HomeMembership
133 Evergreen rd. Suite 203
Louisville, KY 40243

Estimated Cost

$0.00

Per Year

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

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