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.:

 

FA168CPS / FA148CP

Other ______________________________________________________

(circle the appropriate model number)

 

 

 

Type of Alarm:

Installed by:

Burglary

Name

Fire

Serviced by:

Both

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

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First Alert FA168CPSSIA, FA148CPSIA manual OWNER’S Insurance Premium Credit Request