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: |
|
|
|
|
|
|
|
|
|
| Policy No.: |
|
|
|
|
|
|
|
| ||||||||||||
FA130CP |
|
|
|
| Other | ______________________________ |
|
|
|
|
|
|
|
|
|
|
| ||||||||||||||
Type of Alarm: |
|
|
| Burglary |
|
|
|
|
|
| Fire |
|
|
|
|
| Both | ||||||||||||||
|
|
|
|
|
|
|
|
| |||||||||||||||||||||||
Installed by: |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Serviced by: |
|
|
|
|
|
|
|
| ||||||||
|
|
|
|
|
|
|
| Name |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Name | ||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |||
|
|
|
| Address |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Address | ||||||||||
B. NOTIFIES (Insert B = Burglary, F = Fire) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |||||||||||||
Local Sounding Device |
|
|
| Police Dept. |
|
| Fire Dept. |
| |||||||||||||||||||||||
Central Station |
|
|
| Name: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |||||
|
|
|
|
|
| Address: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |||
|
|
|
|
|
| Phone: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |||
C. POWERED BY: A.C. With Rechargeable Power Supply |
|
|
|
|
|
|
|
| |||||||||||||||||||||||
D. TESTING: |
|
|
| Quarterly |
| Monthly |
|
|
|
|
| Weekly |
| Other |
|
| |||||||||||||||
|
|
|
|
|
|
|
|
|
| ||||||||||||||||||||||
continued on other side
– 53 –