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.:

 

 

 

 

 

 

VISTA-21iP /VISTA-21iPSIA________________________________________________ Other

(circle the appropriate model number)

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Alarm:

 

Burglary

 

 

Fire

 

 

 

Both

Installed by:

 

 

 

 

 

 

 

 

Serviced by:

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

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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Image 59
Honeywell VISTA-21IPSIA manual OWNER’S Insurance Premium Credit Request