Insurance Credit Request Form - ADEMCO VISTA-20SE User Manual

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's VISTA 20SE Other ___________________________
Type of Alarm: Burglary
Installed by:
Name
Address
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
Policy No.:
Fire
Serviced by:
Police Dept.
Monthly Weekly
continued on other side
– 47 –
Both
Name
Address
Fire Dept.
Other