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Ð37Ð
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.: _____________________________
First Alert System: FA120C
Type of Alarm: Ê Ê Burglary Ê Ê Fire Ê Ê 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 and Address: _________________________________________________________________________
C . POWERED BY: A.C. With Rechargeable Power Supply
D. TESTING: ÊÊ Quarterly, Ê Ê Monthly, Ê Ê Weekly, Ê Ê Other_________________________________
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