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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.: _______________________________________
First Alert Professional
FA142C System
Type of Alarm: Burglary Fire 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: Quarterly, Monthly, Weekly, Other ___________________________________________
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