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.: _____________________________
First Alert System: | FA120C |
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Type of Alarm: | Ê Ê | Burglary | Ê Ê | Fire | Ê Ê | Both |
Installed by: _________________________________ Serviced by: ___________________________________
name | name |
________________________________ | ___________________________________ |
address | address |
B . NOTIFIES (Insert B for Burglary, F for Fire, where appropriate): | |
Local Sounding Device________ Police Dept.________ | Fire Dept. _______ Central Station ________ |
Name and Address: _________________________________________________________________________
C . POWERED BY: A.C. With Rechargeable Power Supply
D . TESTING: Ê Ê Quarterly, Ê Ê Monthly, Ê Ê Weekly, Ê Ê Other_________________________________
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