OWNER’S INSURANCE PREMIUM CREDIT REQUEST
This form should be completed and forwarded to your homeowner’s insurance carrier for possible premium credit.
A. GENERAL INFORMATION:
Insured’s Name and Address:
Insurance Company: |
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| Policy No.: |
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(circle the appropriate model number) |
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Type of Alarm: |
| Burglary |
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| Fire |
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| Both | |||||||||||
Installed by: |
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| Serviced by: |
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| Name |
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| Name | |||||
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| Address |
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| Address | ||||||||
B. NOTIFIES (Insert B = Burglary, F = Fire) |
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Local Sounding Device |
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| Police Dept. |
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| Fire Dept. |
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Central Station |
| Name: |
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| Address: |
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| Phone: |
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C. POWERED BY: A.C. With Rechargeable Power Supply |
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D. TESTING: | Quarterly | Monthly |
| Weekly | Other |
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continued on other side
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