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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.
Insured's Name and Address:
Insurance Company: Policy No.:
_______________________ Other
Type of Alarm: Burglary Fire Both
Installed by: Serviced by:
Name Name
Address Address
B. NOTIFIES (Insert B = Burglary, F = Fire)
Local Sounding Device Police Dept. Fire Dept.
Central Station
Name: _________________________________________________________________________
Address:
Phone:
A.C. with Rechargeable Power Supply
Quarterly Monthly Weekly Other
E. SMOKE DETECTOR LOCATIONS
Furnace Room Kitchen Bedrooms Attic
Basement Living Room Dining Room Hall
F. BURGLARY DETECTING DEVICE LOCATIONS:
Front Door Basement Door Rear Door All Exterior Doors
1st Floor Windows All Windows Interior Locations
All Accessible Openings, Including Skylights, Air Conditioners and Vents
G. ADDITIONAL PERTINENT INFORMATION:
Signature: Date:
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