![](http://pdfasset.owneriq.net/6/c5/6c56f2ab-4bb2-4dff-874d-0dbab7ab9390/6c56f2ab-4bb2-4dff-874d-0dbab7ab9390-bg3d.png)
– 61 –
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.:
FA168CPS / FA148CP 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