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Owner’s Insurance Premium Credit Requested
This form should be completed and forwarded to your homeowner’s insurance
carrier for possible premium credit.
This control is UL Listed for: UL Grade A Household Burglary
UL Household Fire
A. General Information:
Insured’s Name and Address
Insurance Co.
Policy No:
Moose Security System
Type of Alarm: Burglary Fire Both
Installed by:
Serviced by:
B. Notifies (Insert B=Burglary, F=Fire)
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 Reverse)
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