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36
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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 4110XM
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 __________________________________________________
Address ________________________________________________
Phone __________________________________________________
C. POWERED BY:
A.C. With Rechargeable Power Supply
D. TESTING:
Quarterly, Monthly, Weekly, Other _______________________
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