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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 _______________________
(continued on other side)