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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.:
FA148C
Other
______________________________
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
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