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MAXIMUM INSURANCE DISCOUNT AUTHORIZATION
Dear Insurance Agent,
The installation of my Code-Alarm automatic (passive) arming security system in the vehicle indicated below qualifies me for the maximum discount
mandated by law in some states and by insurance company option in others. This vehicle security system automatically arms itself after the doors are
closed and includes at least one engine disabling relay to prevent the engine from being started.
Insured Signature:
Name(pleaSeprint):
_
Street Address:
State:
Zip:
_
InsuranceCompany:
_
Policy#:
_
Vehicle Year/Make/Model:
_
Vehicle Identification #:
_
The signature below certifies that my Code-Alarm automotive security system was installed on
(date)
_
Installer Signature:
_
Company:
_
Address:
Telephone:
_
PLEASE COMPLETE AND MAIL TO YOUR INSURANCE COMPANY
1026673
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