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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