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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 System: VIA-30PSE VISTA-10SE (check one)
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 and Address: ____________________________________________________________________________________
C . POWERED BY: A.C. With Rechargeable Power Supply
D. TESTING: Quarterly, Monthly, Weekly, Other ___________________________________________
continued on other side