– 53 –
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 VISTA-40 Other
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: _______________________________________________________________________
C. POWERED BY: A.C. With Rechargeable Power Supply
D. TESTING: Quarterly Monthly Weekly Other
continued on other side