Owner's Insurance Credit Request Form - First Alert FA145C 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: Model FA145C
Type of Alarm: 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: Quarterly,
OWNER'S INSURANCE PREMIUM
CREDIT REQUEST
____________________________________________________________________________
Fire
name
address
Police Dept. ___________
Monthly, Weekly,
continued on other side
Both
name
________________________________________
address
Fire Dept. __________
Other _____________________________________________
– 37 –
Central Station __________