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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:
ADEMCO LYNXRIEN-AP ____________________________________________
Type of Alarm:
Burglary
Installed by:
B. NOTIFIES (Insert B = Burglary, F = Fire)
Local Sounding Device
Central Station
Name:_______________________________________________________________________________
Address:
Phone:
C. POWERED BY:
A.C. With Rechargeable Power Supply
D. TESTING:
Quarterly
Name
Address
Police Dept.
Monthly
(continued on other side)
– 47 –
Policy No.:
Other
Fire
Serviced by:
Fire Dept.
Weekly
Other
Both
Name
Address
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