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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.:
VISTA-15 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