Servicer Data - Complete Appliance Protection

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Company Info
Company Name
Physical Address
Street Address City State / Province / Region ZIP / Postal Code
Mailing Address
Same as Physical

Street Address City State / Province / Region ZIP / Postal Code
Phone
Fax
Company Email
Please select business type:
- LLC
- Corporation
How long have you been in business?
Points of Contact
Owner
First Name Last Name
Phone
Email
Service Manager
First Name Last Name
Phone
Email
Billing Contact
First Name Last Name
Phone
Email

Service Information
Please select the items you service:
- Range
- Refrigerator
- Dishwasher
- Clothes Washer
- Clothes Dryer
- Trash Compactor
- Microwave
- Water Heater
- Plumbing
- Electrical
- Air Conditioner
- Furnace
- Heat Pump
- Boiler
- Swamp Cooler
- Septic Systems
- Well Pump
- Pool/Spa Equipment
Please list any brands your company does NOT service
Primary Service Territory
A list of specific zip codes is preferred. You can also list cities, if every zip code in the city is in your territory, or a radius (ie: 10 mile radius of 64068).
How long to you guarantee your:
Labor?
Parts?
Hours of Operation
Do NOT include overtime hours. Enter your start time in the first dropdown and your end time in the second.
Monday - Friday Open
Monday - Friday Close
Saturday Open
Saturday Close
Sunday Open
Sunday Close

Invoice Information
Please select your primary billing method:
- Time and Materials
- Flat Rate
What is your trip charge or diagnostic fee?
What is your labor rate per hour?
What is your markup on parts?
Name of person completing this form:
First Last
Email Address
Zip Codes
Please upload a document containing a list of zip codes for your service area.
Accepted file types: txt, zip, doc, docx, pdf, rtf.

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Company Info