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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.:
VISTA-20P / VISTA-15P Other _____________________________________________________
(circle the appropriate model number)
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:
C. POWERED BY: A.C. With Rechargeable Power Supply
D. TESTING: Quarterly Monthly Weekly Other
continued on other side
National Security Systems Inc (800) 457-1999
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