ADEMCO Security System - OWNERS INSURANCE PREMIUM CREDIT REQUEST

OWNER’S INSURANCE PREMIUM
CREDIT REQUEST
IS form should be completed and forwarded to your homeowner’s insurance carrier for possible premium credit.
GENERAL lNFORMAllON:
Insured’s Name
and Address:
Insuranoe Company:
Policy No.:
ADEMCO System:
4111 XM via30 (circle one)
Type of Alarm:
~ Burglary
Q Fire
~ Both
Installed by:
Serviced by:
name
name
address
address
NOTIFIES (Ineert B for Burglary, F for Fire, where appropriate):
Local Sounding
Device
Police Dept.
Fire Dept
Central Station
Name and Address:
POWERED BY: A.C. Wdh Rechargeable Power Supply
TESTING:
~ Quarterly,
~ Monthly,
~ Weekly,
~ Other
continuedonotherside
-37-