Honeywell LYNXR-I Owners Insurance Premium Credit Request, continued on other side, D. Testing

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 LYNXR-I	______________________________________ Other
Type of Alarm:	Burglary		Fire
Installed by:			Serviced by:
		Name

Address

Both

Name

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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