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: |
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Insurance Company: |
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| Policy No.: | |||
ADEMCO | ______________________________________ Other | |||||||||
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Type of Alarm: |
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| Burglary |
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| Fire | |||
Installed by: |
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| Serviced by: | ||||
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| 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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