OWNER’S INSURANCE PREMIUM
CREDIT REQUEST
rhis form should be completed and forwarded to your homeowner’s insurance carrier for possible premium credit.
4. GENERAL INFORMATION: Insured’s Name and Address:
Insurance | Company: |
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| Policy | No.: |
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ADEMCO | System: | via30+ | VISTA 10 | 411 IXM | (circle one) |
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Type | of Alarm: | ❑ Burglary | ❑ Fire |
| ❑ Both | ||||
Installed | by: |
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| nama |
| Serviced | by: | nama | |
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| addrass |
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| address |
3. NOTIFIES | (Insert | B for | Burglary, | F for Fire, | where appropriate): |
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Local | Sounding | Device |
| Police Dept. |
| Fire Dept. | Central Station | ||
Name | and Address: |
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w. POWERED BY: A.C. With Rechargeable Power Supply
t). TESTING: ❑ Quarterly, ❑ Monthly, ❑ Weekly, n Other
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