Owner's Insurance Premium Credit Request - First Alert FA120C User Manual

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.: _____________________________
First Alert System: FA120C
Type of Alarm: Ê Ê Burglary
Installed by: _________________________________ Serviced by: ___________________________________
________________________________
B . NOTIFIES (Insert B for Burglary, F for Fire, where appropriate):
Local Sounding Device ________
Name and Address: _________________________________________________________________________
C . POWERED BY: A.C. With Rechargeable Power Supply
D . TESTING: Ê Ê Quarterly,
OWNER'S INSURANCE PREMIUM
CREDIT REQUEST
__________________________________________________________________
Ê Ê Fire
name
address
Police Dept. ________
Ê Ê Monthly, Ê Ê Weekly,
continued on other side
Ð 3 7 Ð
Ê Ê Both
name
___________________________________
address
Fire Dept. _______ Central Station ________
Ê Ê Other_________________________________