Vendor enrollment packet
Contents
1. Exempt payee Address number street and apt or suite no Requester s name and address optional City state and ZIP code Print or type See Specific Instructions on page 2 List account number s here optional Part I Taxpayer Identification Number TIN Enter your TIN in the appropriate box The TIN provided must match the name given on the Name line to avoid backup withholding For individuals this is your social security number SSN However for a resident alien sole proprietor or disregarded entity see the Part instructions on page 3 For other entities it is your employer identification number EIN If you do not have a number see How to get a TIN on page 3 Note If the account is in more than one name see the chart on page 4 for guidelines on whose number to enter Social security number Employer identification number Certification Under penalties of perjury certify that 1 The number shown on this form is my correct taxpayer identification number or am waiting for a number to be issued to me and 2 am not subject to backup withholding because a am exempt from backup withholding or b have not been notified by the Internal Revenue Service IRS that am subject to backup withholding as a result of a failure to report all interest or dividends or c the IRS has notified me th2. HSA Contractor Background Screening Portal Powered by Acxiom New users will then read and accept adverse action and consumer rights obligations under the Fair Credit Reporting Act FCRA Please remember to save you user name and password in a secure location for future use To obtain a consent form if running a background check on anyone other than you click on the Sample Release link in the top left corner under the Acxiom Logo To begin the background check ordering process click on Order a Background Report on the right side of your screen Select the HSA Approved Contractor Package on the next screen and click submit Enter in the appropriate information on the applicant information screen You must include the full name social security number no dashes and date of birth 00 00 0000 format at a minimum for each applicant Verify all information is correct and click Submit Click on Submit on the following page as well and you will arrive at the payment screen Enter in your name address and credit card information and click on Submit Once your order is submitted generally allow 1 3 business days for results to post A copy of the completed report will be sent to Home Security of America for review For assistance with this process please contact Acxiom Customer Service between the hours of 8 00 AM 11 00 PM EST Monday through Friday customermail acxiom com 1 800 853
3. SM HSA HOME WARRANTY PROTECTION The Right Home Warranty Preferred Service Provider Thank you for your interest in becoming an HSA Home Warranty Preferred Service Provider Since 1984 HSA has provided valuable home warranty coverage for homeowners saving them from the expense and aggravation of home repairs With this protection a homeowner turns to HSA to help pay for the cost of repairing or replacing appliances or mechanical systems that fail due to normal wear and tear during the coverage period At HSA we take great pride in our industry leading service and our network of Preferred Service Contractors is critical to our success Our ability to retain our customers starts with the experience they have when they use our policy That experience is largely defined by you and we know and appreciate the value you can bring to our homeowners and real estate clients With HSA Home Warranty you can be sure that our commitment to excellent customer service ex tends to all our partners homeowners real estate agents and service providers Are you a ser vice provider committed to the same high standards If so partnering with HSA can e Grow your business e Keep your techs busy e Keep the checks coming e Get you direct no bid referrals every time e Save on advertising costs On the next page you will find a checklist showing the forms licenses and next steps required to become a preferred service provider Soon after we ve recei
4. certify that the information provided above is true Name of Company Printed name of person authorized to sign Signature Date Home Security of America Inc HSA Home Warranty considers this information to be proprietary and confedential Access is limited to authorized per sons Do not copy and or distribute without express written permission from HSA Home Warrany Form 8 SM HSA HOME WARRANTY PROTECTION The Right Home Warranty Preferred Service Provider LEAD BASED PAINT RENOVATION REPAIR AND PAINTING PROGRAM RULE On April 22 2010 the EPA s 2008 Lead Based Paint Renovation Repair and Painting Program Rule became fully effective EPA states this rule is aimed at protecting against lead based paint hazards associated with renovation repair and painting activities You can find a copy of the rule at http www epa gov lead pubs renovation You will also find a helpful reference handbook explaining the rule at http www epa gov lead pubs sbcomplianceguide pdf HSA requests that you read the full rule as well as the brochure After you have completed your review of this information please sign the agreement below The Agreement simply states you have been notified of the Rule and agree to comply with the Rule on any service call in response to an HSA dis patch Please visit onlinehsa com for more information LEAD BASED PAINT AGREEMENT On behalf of Company attest am authorized to represent an
5. 3228 Option 2 Form 10 IOM ben The Right Home Warranty WE MAKE INFORMATION INTELLIGENT If your company has already conducted background checks that meet HSA requirements please supply the following information as well as a copy of the completed background check for each technician Firm that preformed background checks Address of firm City State Zip Code Phone number of firm By signing below you agree to have had a background check performed on all of your employees who will have access to the private residence of any HSA contract holder You also agree that if any employee s background check has not met the standards established by HSA you will not dispatch said employee on any service calls initiated by HSA or an HSA contract holder Signature of company owner Date Form 10
6. 9 You may be requested to sign by the withholding agent even if item 1 below and items 4 and 5 on page 4 indicate otherwise For a joint account only the person whose TIN is shown in Part should sign when required In the case of a disregarded entity the person identified on the Name line must sign Exempt payees see Exempt Payee on page 3 Signature requirements Complete the certification as indicated in items 1 through 3 below and items 4 and 5 on page 4 1 Interest dividend and barter exchange accounts opened before 1984 and broker accounts considered active during 1983 You must give your correct TIN but you do not have to sign the certification 2 Interest dividend broker and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983 You must sign the certification or backup withholding will apply If you are subject to backup withholding and you are merely providing your correct TIN to the requester you must cross out item 2 in the certification before signing the form 3 Real estate transactions You must sign the certification You may cross out item 2 of the certification Form W 9 Rev 12 2011 4 Other payments You must give your correct TIN but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN Other payments include payments made in the course of the requester s trade or business
7. conducting a trade or business in the United States provide Form W 9 to the partnership to establish your U S status and avoid withholding on your share of partnership income Form W 9 Rev 12 2011 Form W 9 Rev 12 2011 The person who gives Form W 9 to the partnership for purposes of establishing its U S status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases e The U S owner of a disregarded entity and not the entity e The U S grantor or other owner of a grantor trust and not the trust and e The U S trust other than a grantor trust and not the beneficiaries of the trust Foreign person If you are a foreign person do not use Form W 9 Instead use the appropriate Form W 8 see Publication 515 Withholding of Tax on Nonresident Aliens and Foreign Entities Nonresident alien who becomes a resident alien Generally only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U S tax on certain types of income However most tax treaties contain a provision known as a saving clause Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U S resident alien for tax purposes If you are a U S resident alien who is relying on an exception contained in the saving clause o
8. for rents royalties goods other than bills for merchandise medical and health care services including payments to corporations payments to a nonemployee for services payments to certain fishing boat crew members and fishermen and gross proceeds paid to attorneys including payments to corporations 5 Mortgage interest paid by you acquisition or abandonment of secured property cancellation of debt qualified tuition program payments under section 529 IRA Coverdell ESA Archer MSA or HSA contributions or distributions and pension distributions You must give your correct TIN but you do not have to sign the certification What Name and Number To Give the Requester For this type of account Give name and SSN of 1 2 Individual Two or more individuals joint account Custodian account of a minor Uniform Gift to Minors Act a The usual revocable savings trust grantor is also trustee b So called trust account that is not a legal or valid trust under state law Sole proprietorship or disregarded entity owned by an individual Grantor trust filing under Optional Form 1099 Filing Method 1 see Regulation section 1 671 4 b 2 i A For this type of account The individual The actual owner of the account or if combined funds the first individual on the account The minor The grantor trustee The actual owner The owner The grantor Give name and EIN
9. for a number to be issued 2 Certify that you are not subject to backup withholding or 3 Claim exemption from backup withholding if you are a U S exempt payee If applicable you are also certifying that as a U S person your allocable share of any partnership income from a U S trade or business is not subject to the withholding tax on foreign partners share of effectively connected income Cat No 10231X Date gt Note If a requester gives you a form other than Form W 9 to request your TIN you must use the requester s form if it is substantially similar to this Form W 9 Definition of a U S person For federal tax purposes you are considered a U S person if you are e An individual who is a U S citizen or U S resident alien e A partnership corporation company or association created or organized in the United States or under the laws of the United States e An estate other than a foreign estate or e A domestic trust as defined in Regulations section 301 7701 7 Special rules for partnerships Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners share of income from such business Further in certain cases where a Form W 9 has not been received a partnership is required to presume that a partner is a foreign person and pay the withholding tax Therefore if you are a U S person that is a partner in a partnership
10. of 11 12 13 Disregarded entity not owned by an individual A valid trust estate or pension trust Corporation or LLC electing corporate status on Form 8832 or Form 2553 Association club religious charitable educational or other tax exempt organization Partnership or multi member LLC A broker or registered nominee Account with the Department of Agriculture in the name of a public entity such as a state or local government school district or prison that receives agricultural program payments Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 see Regulation section 1 671 4 b 2 i B The owner Legal entity The corporation The organization The partnership The broker or nominee The public entity The trust i List first and circle the name of the person whose number you furnish If only one person on a joint account has an SSN that person s number must be furnished Circle the minor s name and furnish the minor s SSN You must show your individual name and you may also enter your business or DBA name on the Business name disregarded entity name line You may use either your SSN or EIN if you have one but the IRS encourages you to use your SSN 4 List first and circle the name of the trust estate or pension trust Do not furnish the TIN of the personal representative or trustee unless the leg
11. Code requires you to provide your correct TIN to persons including federal agencies who are required to file information returns with the IRS to report interest dividends or certain other income paid to you mortgage interest you paid the acquisition or abandonment of secured property the cancellation of debt or contributions you made to an IRA Archer MSA or HSA The person collecting this form uses the information on the form to file information returns with the IRS reporting the above information Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities states the District of Columbia and U S possessions for use in administering their laws The information also may be disclosed to other countries under a treaty to federal and state agencies to enforce civil and criminal laws or to federal law enforcement and intelligence agencies to combat terrorism You must provide your TIN whether or not you are required to file a tax return Under section 3406 payers must generally withhold a percentage of taxable interest dividend and certain other payments to a payee who does not give a TIN to the payer Certain penalties may also apply for providing false or fraudulent information SM aa ee IY LONG The Right Home Warranty WE MAKE INFORMATION INTELLIGENT HSA Contractor Background Screening Portal Powered by Acxiom All contractors providing services in connection with an
12. HSA claim or job must be approved by Home Security of America and must undergo a thorough background check as part of the credentialing process 1 Contractors may access the secure background screening portal online by accessing https smwreports sterlingdirect com Consumer contractor as 2 Iftechnicians have already completed background checks that meet HSA requirements please skip to the last page 2 Firsttime users will need to create an account initially by entering the partner code HOME7363 and selecting I am a new user Returning users may enter in the same partner code of HOME7363 and entering their user name and password Returning users may skip to step 7 at this time ACXIOM ACXIOM INFORMATION SECURITY SERVICES MyBackgroundReport com providing backgrounds to individuals and companies Partner lueaisaacl O ae HSA12345 I have already registered my account Login Password Forgot your password ENTER I ama New User uit 3 New users will enter their company information on the set up screen including business and contact name address phone fax email information 4 New users will create a login and a password If you need any assistance with this step please contact Acxiom s customer service group at 1 800 853 3228 and select option 2 Click submit to move to the next step 9 10 1 m 12 OM The Right Home Warranty WE MAKE INFORMATION INTELLIGENT
13. ND CHECKS Each technician is required to complete a background check HSA has partnered with Acxiom so the back ground checks can be completed easily and efficiently Please refer to the Acxiom Instruction Packet to learn how to begin this process TRADE CALL FEES HSA contracts require the customer to pay a trade call fee on every approved trade call except when specifi cally waived by HSA The trade call fee amount ranges from 40 100 The technician must collect the trade call fee directly from the customer In the event a claim is not approved charges will be limited to service call or trade call fee whichever is lower unless accessing or overtime were authorized by the customer Home Security of America Inc HSA Home Warranty considers this information to be proprietary and confedential Access is limited to authorized persons Do not copy and or distribute without express written permission from HSA Home Warrany Form 5 SM HSA HOME WARRANTY PROTECTION The Right Home Warranty Preferred Service Provider STATEMENT OF SERVICE OYes UNo We will report all conditions of maintenance neglect or homeowner tampering Before beginning any service work we will obtain authorization as needed by HSA OYes UNo We will comply with the Service Priority as identified on each dispatch OYes UNo We will follow all procedures identified in the HSA 101 document Form 5 Standard Service We agree to telephone the cust
14. al entity itself is not designated in the account title Also see Special rules for partnerships on page 1 Note Grantor also must provide a Form W 9 to trustee of trust Page 4 Note If no name is circled when more than one name is listed the number will be considered to be that of the first name listed Secure Your Tax Records from Identity Theft Identity theft occurs when someone uses your personal information such as your name social security number SSN or other identifying information without your permission to commit fraud or other crimes An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund To reduce your risk e Protect your SSN e Ensure your employer is protecting your SSN and e Be careful when choosing a tax preparer If your tax records are affected by identity theft and you receive a notice from the IRS respond right away to the name and phone number printed on the IRS notice or letter If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet questionable credit card activity or credit report contact the IRS Identity Theft Hotline at 1 800 908 4490 or submit Form 14039 For more information see Publication 4535 Identity Theft Prevention and Victim Assistance Victims of identity theft who are experiencing economic harm or a system problem or are seeking help in resolvin
15. at am no longer subject to backup withholding and 3 am a U S citizen or other U S person defined below Certification instructions You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return For real estate transactions item 2 does not apply For mortgage interest paid acquisition or abandonment of secured property cancellation of debt contributions to an individual retirement arrangement IRA and generally payments other than interest and dividends you are not required to sign the certification but you must provide your correct TIN See the instructions on page 4 Signature of U S person gt General Instructions Section references are to the Internal Revenue Code unless otherwise noted Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number TIN to report for example income paid to you real estate transactions mortgage interest you paid acquisition or abandonment of secured property cancellation of debt or contributions you made to an IRA Use Form W 9 only if you are a U S person including a resident alien to provide your correct TIN to the person requesting it the requester and when applicable to 1 Certify that the TIN you are giving is correct or you are waiting
16. ation of the owner identified on the Name line Form W 9 Rev 12 2011 Other entities Enter your business name as shown on required federal tax documents on the Name line This name should match the name shown on the charter or other legal document creating the entity You may enter any business trade or DBA name on the Business name disregarded entity name line Exempt Payee If you are exempt from backup withholding enter your name as described above and check the appropriate box for your status then check the Exempt payee box in the line following the Business name disregarded entity name sign and date the form Generally individuals including sole proprietors are not exempt from backup withholding Corporations are exempt from backup withholding for certain payments such as interest and dividends Note If you are exempt from backup withholding you should still complete this form to avoid possible erroneous backup withholding The following payees are exempt from backup withholding 1 An organization exempt from tax under section 501 a any IRA or a custodial account under section 403 b 7 if the account satisfies the requirements of section 401 f 2 2 The United States or any of its agencies or instrumentalities 3 A state the District of Columbia a possession of the United States or any of their political subdivisions or instrumentalities 4 A foreign government or any
17. d accounts opened after 1983 only Page 2 Certain payees and payments are exempt from backup withholding See the instructions below and the separate Instructions for the Requester of Form W 9 Also see Special rules for partnerships on page 1 Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person For example you may need to provide updated information if you are a C corporation that elects to be an S corporation or if you no longer are tax exempt In addition you must furnish a new Form W 9 if the name or TIN changes for the account for example if the grantor of a grantor trust dies Penalties Failure to furnish TIN If you fail to furnish your correct TIN to a requester you are subject to a penalty of 50 for each such failure unless your failure is due to reasonable cause and not to willful neglect Civil penalty for false information with respect to withholding If you make a false statement with no reasonable basis that results in no backup withholding you are subject to a 500 penalty Criminal penalty for falsifying information Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and or imprisonment Misuse of TINs If the requester discloses or uses TINs in violation of federal law th
18. d sign this Agreement on behalf of the Company further attest that have read and understood the EPA s 2008 Lead Based Paint Renovations Repair and Painting Program Rule which became fully effective April 22 2010 The Company and its employees agree to FULLY COMPLY with the EPA s 2008 Lead Based Paint Renovations Repair and Painting Program Rule on all service calls dispatched by Home Security of America Inc HSA or any of its affiliates or subsidiaries Date Signature Print Name Title Company Address Company Phone Home Security of America Inc HSA Home Warranty considers this information to be proprietary and confedential Access is limited to authorized per sons Do not copy and or distribute without express written permission from HSA Home Warrany Form 9 Form W 9 Rev December 2011 Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification Give Form to the requester Do not send to the IRS Name as shown on your income tax return Business name disregarded entity name if different from above Check appropriate box for federal tax classification Individual sole proprietor C Corporation S Corporation O Other see instructions gt Partnership O Trust estate O Limited liability company Enter the tax classification C C corporation S S corporation P partnership gt
19. e requester may be subject to civil and criminal penalties Specific Instructions Name If you are an individual you must generally enter the name shown on your income tax return However if you have changed your last name for instance due to marriage without informing the Social Security Administration of the name change enter your first name the last name shown on your social security card and your new last name If the account is in joint names list first and then circle the name of the person or entity whose number you entered in Part of the form Sole proprietor Enter your individual name as shown on your income tax return on the Name line You may enter your business trade or doing business as DBA name on the Business name disregarded entity name line Partnership C Corporation or S Corporation Enter the entity s name on the Name line and any business trade or doing business as DBA name on the Business name disregarded entity name line Disregarded entity Enter the owner s name on the Name line The name of the entity entered on the Name line should never be a disregarded entity The name on the Name line must be the name shown on the income tax return on which the income will be reported For example if a foreign LLC that is treated as a disregarded entity for U S federal tax purposes has a domestic owner the domestic owner s name is required to be provid
20. ed on the Name line If the direct owner of the entity is also a disregarded entity enter the first owner that is not disregarded for federal tax purposes Enter the disregarded entity s name on the Business name disregarded entity name line If the owner of the disregarded entity is a foreign person you must complete an appropriate Form W 8 Note Check the appropriate box for the federal tax classification of the person whose name is entered on the Name line Individual sole proprietor Partnership C Corporation S Corporation Trust estate Limited Liability Company LLC If the person identified on the Name line is an LLC check the Limited liability company box only and enter the appropriate code for the tax classification in the space provided If you are an LLC that is treated as a partnership for federal tax purposes enter P for partnership If you are an LLC that has filed a Form 8832 or a Form 2553 to be taxed as a corporation enter C for C corporation or S for S corporation If you are an LLC that is disregarded as an entity separate from its owner under Regulation section 301 7701 3 except for employment and excise tax do not check the LLC box unless the owner of the LLC required to be identified on the Name line is another LLC that is not disregarded for federal tax purposes If the LLC is disregarded as an entity separate from its owner enter the appropriate tax classific
21. ervice call 1 4 hourly rate RETAIL PARTS CHARGES Parts Cost Range Markup Parts Cost Range Markup EXAMPLE Parts Cost Range Markup Parts Cost Range Markup 1 200 30 lt 100 100 151 200 25 lt 50 200 ADDITIONAL PRICING COMMENTS AND NOTES Home Security of America Inc HSA Home Warranty considers this information to be proprietary and confedential Access is limited to authorized per sons Do not copy and or distribute without express written permission from HSA Home Warrany Form 2 SM SaaS SSS HSA HOME WARRANTY PROTECTION The Right Home Warranty Equipment Information DEALER AND EQUIPMENT INFORMATION We are dealers of these brands We service these brands We do not service these brands Name location and phone number of the nearest Ferguson distributor water heater Name location and phone number of the nearest Carrier distributor HVAC Name location and phone number of the nearest Goodman distributor HVAC Name location and phone number of the nearest Lennox distributor HVAC EQUIPMENT WAREHOUSES YOU USE This distributor sells the following check all that apply Heating and air conditioning UPlumbing UAppliance Name Phone Address City Zip Code This distributor sells the following check all that apply OHeating and air conditioning UPlumbing OAppliance Name Phone Address City Z
22. f a tax treaty to claim an exemption from U S tax on certain types of income you must attach a statement to Form W 9 that specifies the following five items 1 The treaty country Generally this must be the same treaty under which you claimed exemption from tax as a nonresident alien 2 The treaty article addressing the income 3 The article number or location in the tax treaty that contains the saving clause and its exceptions 4 The type and amount of income that qualifies for the exemption from tax 5 Sufficient facts to justify the exemption from tax under the terms of the treaty article Example Article 20 of the U S China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States Under U S law this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years However paragraph 2 of the first Protocol to the U S China treaty dated April 30 1984 allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States A Chinese student who qualifies for this exception under paragraph 2 of the first protocol and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W 9 a statement that includes the information described above to support that exem
23. g tax problems that have not been resolved through normal channels may be eligible for Taxpayer Advocate Service TAS assistance You can reach TAS by calling the TAS toll free case intake line at 1 877 777 4778 or TTY TDD 1 800 829 4059 Protect yourself from suspicious emails or phishing schemes Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft The IRS does not initiate contacts with taxpayers via emails Also the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers passwords or similar secret access information for their credit card bank or other financial accounts If you receive an unsolicited email claiming to be from the IRS forward this message to phishing irs gov You may also report misuse of the IRS name logo or other IRS property to the Treasury Inspector General for Tax Administration at 1 800 366 4484 You can forward suspicious emails to the Federal Trade Commission at spam uce gov or contact them at www ftc gov idtheft or 1 877 IDTHEFT 1 877 438 4338 Visit IRS gov to learn more about identity theft and how to reduce your risk Privacy Act Notice Section 6109 of the Internal Revenue
24. hat occur during the time frame of warranty coverage HSA will rely on your professional opinion to make informed and accurate claim decisions for our customers All parts and equipment must be replaced with new equipment refurbished equipment is not allowed HOURS OF OPERATION Twenty four hours a day seven days a week DISPATCHES If a dispatch is recieved as standard service the customer should be called within two hours and service should be scheduled within forty eight hours If a dispatch is recieved as emergency ser vice the customer should be contacted within thirty minutes and service should be scheduled within four hours If you are unable to contact the customer within the appropriate time frame please call our service line to notify us We believe service excellence consists of meeting and exceeding our customers expectations This begins with a smooth dispatch and scheduling process APPEARANCE AND PROFESSIONALISM When at a customer s home you are representing HSA and it is important to us that you reflect a positive and professional manner at all times We require vendors to value personal cleanliness and be properly groomed Also the condition and cleanliness of a workspace is a key performance indicator when evaluating vendor performance Be positive when in a customer s home avoid making negative comments that may upset the customer whether the comment is regarding the job HSA or other vendors BACKGROU
25. ices L List of technicians NEXT STEPS PROTECTION Checklist SM EE E EE _ E _ Ss The Right Home Warranty Once HSA has been provided with all of the above information you will then be provided with eService Agreement Pricing Sheet eAny State Specific Forms if applicable You must sign and return both agreements Upon receipt of the signed contracts HSA will then send a welcome packet that includes a sample contract and service manual Home Security of America Inc HSA Home Warranty considers this information to be proprietary and confedential Access is limited to authorized persons Do not copy and or distribute without express written permission from HSA Home Warrany HSA HOME WARRANTY PROTECTION The Right Home Warranty Company Profile GENERAL INFORMATION Business Name Federal Tax ID Mailing Address Office Other Address City State Zip Code Owner Other Contact Service Manager Business Phone Fax Cell Phone Emergency Phone Email address Website DISPATCH PREFERENCE Please select the method s you would like HSA customers to be referred to your company maximum of two methods g Via e mail at g Via fax at O Please have the customer contact us directly by phone at STAFF PROFILE please provide a list of names first amp last of all technicians Number of technicians How are they identifiable nametag badges unif
26. ip Code This distributor sells the following check all that apply QOlHeating and air conditioning UPlumbing OAppliance Name Phone Address City Zip Code This distributor sells the following check all that apply QOiHeating and air conditioning UPlumbing OAppliance Name Phone Address City Zip Code Home Security of America Inc HSA Home Warranty considers this information to be proprietary and confedential Access is limited to authorized persons Do not copy and or distribute without express written permission from HSA Home Warrany Form 3 HSA Service Profile HOME WARRANTY PROTECTION SM E The Right Home Warranty HVAC We will install HSA Provided Equipment OYes No Water heaters We will install HSA Provided Equipment QYes No Please check all that are applicable services Air Conditioning Cooler Swamp OiGlycol Duct Work Heating OQElectric Radiant OiGlycol C Wall Unit Heat Pump OForced Air Electric OGlycol Plumbing Water Heater Water Softener OlLines Gas OiMain Line Routing Septic Pumping Appliances OiWasher Dryer Magnetic Induction Range Fan Hood Electrical OCentral Vacuum QOAttic Fan CiReceptacle Structural Olnterior Wall Crack Swimming Pool Q Hot Tub QForced Air Electric C Wall Unit CiForced Air OIHot Water Steam Duct Work UForced Air Gas UiWater Source UTankless Water Heater Wa
27. nty considers this information to be proprietary and confedential Access is limited to authorized per sons Do not copy and or distribute without express written permission from HSA Home Warrany Form 7 SM u HSA HOME WARRANTY PROTECTION The Right Home Warranty Preferred Service Provider CORPORATE EXEMPTION FORM In order for us to properly maintain our records for the purpose of issuing a Form 1099 Information Returns HSA Home Warranty requests that you furnish the following information Is your company or business registered as a corporation O Yes If yes simply sign and date this from and return it to HSA Home Warranty We will not issue a 1099 Infor mation Return to the Internal Revenue Service nor will we deduct 30 backup withholding on payments O No If no we are required to issue a Form 1099 Information Return to the Internal Revenue Service and as such you are required by law to furnish us with your Federal Identification Number Please complete the attached Form W 9 If we do not receive this letter or a properly executed Form W 9 as required by law we will withhold 30 of the amount we owe you and remit the withheld amounts to the Internal Revenue Service In addition you may be subject to a 50 penalty imposed by the Internal Revenue Service for failure to provide the proper Federal Identification Number We appreciate your cooperation in this matter Under penalties of perjury
28. of its political subdivisions agencies or instrumentalities or 5 An international organization or any of its agencies or instrumentalities Other payees that may be exempt from backup withholding include 6 A corporation 7 A foreign central bank of issue 8 A dealer in securities or commodities required to register in the United States the District of Columbia or a possession of the United States 9 A futures commission merchant registered with the Commodity Futures Trading Commission 10 A real estate investment trust 11 An entity registered at all times during the tax year under the Investment Company Act of 1940 12 A common trust fund operated by a bank under section 584 a 13 A financial institution 14 A middleman known in the investment community as a nominee or custodian or 15 A trust exempt from tax under section 664 or described in section 4947 The following chart shows types of payments that may be exempt from backup withholding The chart applies to the exempt payees listed above 1 through 15 IF the payment is for THEN the payment is exempt for Interest and dividend payments All exempt payees except for 9 Broker transactions Exempt payees 1 through 5 and 7 through 13 Also C corporations Barter exchange transactions and patronage dividends Exempt payees 1 through 5 Payments over 600 required to be Generally exempt payees reported and direct sales over 1
29. omer within two hours and to schedule the service call within forty eight hours of receipt of the dispatch If we are unable to meet this time frame we agree to notify HSA Emergency Service We agree to telephone the customer within thirty minutes and to schedule the service call within four hours of receipt of the dispatch If we are unable to meet this time frame we agree to notify HSA Signature Printed name Date Name of company Home Security of America Inc HSA Home Warranty considers this information to be proprietary and confedential Access is limited to authorized persons Do not copy and or distribute without express written permission from HSA Home Warrany Form 6 SM E HSA HOME WARRANTY PROTECTION The Right Home Warranty Preferred Service Provider WORKERS COMPENSATION WAIVER My company is exempt from Workers Compensation because am a sole proprietor owner or part ner of a business that is not required to purchase Workers Compensation Insurance coverage in my state based on current state laws If Workers Compensation Insurance should become necessary due to the addition of employees or change of current state laws will promptly provide a Certificate of Insurance to HSA Home Warranty indicating Workers Compensation Coverage Business Name Mailing Address City State Zip Code Owner s Name Owner s Signature Date Home Security of America Inc HSA Home Warra
30. or get this form online at www ssa gov You may also get this form by calling 1 800 772 1213 Use Form W 7 Application for IRS Individual Taxpayer Identification Number to apply for an ITIN or Form SS 4 Application for Employer Identification Number to apply for an EIN You can apply for an EIN online by accessing the IRS website at www irs gov businesses and clicking on Employer Identification Number EIN under Starting a Business You can get Forms W 7 and SS 4 from the IRS by visiting IRS gov or by calling 1 800 TAX FORM 1 800 829 3676 If you are asked to complete Form W 9 but do not have a TIN write Applied For in the space for the TIN sign and date the form and give it to the requester For interest and dividend payments and certain payments made with respect to readily tradable instruments generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments The 60 day rule does not apply to other types of payments You will be subject to backup withholding on all such payments until you provide your TIN to the requester Note Entering Applied For means that you have already applied for a TIN or that you intend to apply for one soon Caution A disregarded domestic entity that has a foreign owner must use the appropriate Form W 8 Part Il Certification To establish to the withholding agent that you are a U S person or resident alien sign Form W
31. orms etc Number of service vehicles How are they identifiable logos signs lettering FJ All service technicians have completed required background checks See Form 11 SERVICE HOURS amp CHARGES Primary service area zip code lists attached LYes LINo Please attach an excel spreadsheet or list of the zip codes your company services Also please include any additional charges that may apply for areas outside of your normal service area Service Hours Monday Friday Saturday Sunday Staffed Office Hours Standard Service Hours Overtime Service Hours Holiday Service Hours Home Security of America Inc HSA Home Warranty considers this information to be proprietary and confedential Access is limited to authorized persons Do not copy and or distribute without express written permission from HSA Home Warrany F 1 orm SM HSA HOME WARRANTY PROTECTION The Right Home Warranty Pricing Information HSA PREFERRED SERVICE CHARGES DISCOUNTED RATES FOR HSA Normal Hours Overtime Evenings Saturdays Overtime Sundays Holidays Service call Labor 1 4 hourly rate HSA PARTS COST DISCOUNTED RATES FOR HSA Parts Cost Range Markup Parts Cost Range Markup RETAIL SERVICE CHARGES BaiamEanre Overtime Overtime g Evenings Saturdays Sundays Holidays Labor s
32. ption If you are a nonresident alien or a foreign entity not subject to backup withholding give the requester the appropriate completed Form W 8 What is backup withholding Persons making certain payments to you must under certain conditions withhold and pay to the IRS a percentage of such payments This is called backup withholding Payments that may be subject to backup withholding include interest tax exempt interest dividends broker and barter exchange transactions rents royalties nonemployee pay and certain payments from fishing boat operators Real estate transactions are not subject to backup withholding You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN make the proper certifications and report all your taxable interest and dividends on your tax return Payments you receive will be subject to backup withholding if 1 You do not furnish your TIN to the requester 2 You do not certify your TIN when required see the Part II instructions on page 3 for details 3 The IRS tells the requester that you furnished an incorrect TIN 4 The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return for reportable interest and dividends only or 5 You do not certify to the requester that you are not subject to backup withholding under 4 above for reportable interest and dividen
33. ter Well OiLateral Routing LWater Heater Power Vent OiDishwasher OlOven Range Olce maker dispenser ODoor Bell QIExhaust Fan OiWiring General Repair LiFoundation Wall Crack OSwimming Pool We prefer UPick Up We prefer UPick Up Packaged Units Window Unit Packaged Units OSolar OHumidifier OiPackaged Units Duct Work Sump Pump ULines Water UiGarbage Disposal QWater Purifiers OiFreezer OiRefrigerator QOWExhaust Venting Garage Door Opener QBreaker Fuse Panel ULight Fixtures QRoof Leak Repairs Whirlpool Bath Delivery Delivery CiGeo Thermal OElectronic Air Filters AGeo Thermal OOil Furnaces AGeo Thermal UEjector Lift Pump ULines Drain UDrain Camera Septic Service QMicrowave Compactor Olntercom OCeiling Fan OlSecurity System Drywall Home Security of America Inc HSA Home Warranty considers this information to be proprietary and confedential Access is limited to authorized persons Do not copy and or distribute without express written permission from HSA Home Warrany Form 4 SM HSA HOME WARRANTY PROTECTION The Right Home Warranty HSA 101 HSA Home Warranty 1861 Ludden Dr Cross Plains WI 53528 Service Number 1 800 367 1448 Fax Number 1 877 638 1741 Vendor Hotline to call in claim information 1 877 683 6967 www onlinehsa com COVERAGE HSA Home Warranty contracts cover failures due to normal wear and tear t
34. through 7 5 000 See Form 1099 MISC Miscellaneous Income and its instructions However the following payments made to a corporation and reportable on Form 1099 MISC are not exempt from backup withholding medical and health care payments attorneys fees gross proceeds paid to an attorney and payments for services paid by a federal executive agency Page 3 Part I Taxpayer Identification Number TIN Enter your TIN in the appropriate box If you are a resident alien and you do not have and are not eligible to get an SSN your TIN is your IRS individual taxpayer identification number ITIN Enter it in the social security number box If you do not have an ITIN see How to get a TIN below If you are a sole proprietor and you have an EIN you may enter either your SSN or EIN However the IRS prefers that you use your SSN If you are a single member LLC that is disregarded as an entity separate from its owner see Limited Liability Company LLC on page 2 enter the owner s SSN or EIN if the owner has one Do not enter the disregarded entity s EIN If the LLC is classified as a corporation or partnership enter the entity s EIN Note See the chart on page 4 for further clarification of name and TIN combinations How to get a TIN If you do not have a TIN apply for one immediately To apply for an SSN get Form SS 5 Application for a Social Security Card from your local Social Security Administration office
35. ved the forms the vendor territory manager for your area will get in touch with you Your territory manager will help set you up as a preferred vendor and will continue to serve as your partner in providing HSA s customers with world class service We will be working together in no time Thank you Christopher Riechers Vendor and Supply Chain Director Vendor Relations Department Home Security of America Inc HSA Home Warranty considers this information to be proprietary and confedential Access is limited to authorized persons Do not copy and or distribute without express written permission from HSA Home Warrany HSA HOME WARRANTY Preferred Service Provider PLEASE COMPLETE AND RETURN CL Company Profile Form 1 L Pricing Information Form 2 O Equipment Information Form 3 L Service Profile Form 4 L Statement of Service Form 6 O Workers Compensation Waiver Form 7 O Corporate Exemption Form Form 8 O Lead Based Paint Agreement Form 9 O Background Check Agreement Form 10 O Form W 9 PLEASE PROVIDE Copies of all applicable trade licenses and certifications O Heating O Air Conditioning O Plumbing O Electrical O EPA Certification for refrigeration and HVAC CL State County Municipal O Bond declarations if applicable Copies of current insurance certificates O General liability O Automobile O Workers Compensation O Workers Compensation Waiver O List of zip codes your company serv
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