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OWNER’S INSURANCE PREMIUM
CREDIT REQUEST
rhis form should be completed and forwarded to your homeowner’s insurance carrier for possible premium credit.
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GENERAL INFORMATION:
Insured’s Name and Address:
Insurance Company:
Policy No.:
ADEMCO System: via30+
VISTA 10 411 IXM (circle one)
Type of Alarm:
❑ Burglary
❑ Fire
❑ Both
Installed by:
Serviced by:
nama
nama
addrass
address
NOTIFIES (Insert B for Burglary, F for
Fire, where appropriate):
Local Sounding Device
Police Dept.
Fire Dept.
Central Station
Name and Address:
POWERED BY: A.C. With Rechargeable Power Supply
TESTING:
❑ Quarterly, ❑ Monthly, ❑ Weekly, n Other
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