Honeywell 4110XM Home Security System User Manual


 
36
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)