OWNER'S INSURANCE PREMIUMCREDIT 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 System:

VIA-30PSE

 

VISTA-10SE

 

(check one)

Type of Alarm:

 

Burglary

 

 

Fire

 

 

Both

 

 

 

 

 

Installed by: _______________________________________Serviced by: ________________________________________

name

name

______________________________________

________________________________________

address

address

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

Local Sounding Device _________ Police Dept.___________ Fire Dept. __________ Central Station __________

Name and Address: ____________________________________________________________________________________

C .

POWERED BY: A.C. With Rechargeable Power Supply

 

D .

TESTING:

 

Quarterly,

 

Monthly,

 

Weekly,

 

Other ___________________________________________

 

 

 

 

continued on other side

– 3 7 –