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.: ________________________

ADEMCO 4110XM

 

 

Type of Alarm:

Burglary

Fire

Both

Installed by: _______________________________Serviced by: _______________________________

NameName

___________________________________

_______________________________

Address

Address

B. NOTIFIES (Insert B for Burglary, F for Fire, where appropriate):

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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Honeywell manual Owners Insurance Premium Credit Request, Ademco 4110XM