
OWNER’S INSURANCE PREMIUM CREDIT REQUEST
Thisform should be completed and forwarded to your homeowner’s insurance carrier for possible premium credit.
A.
GENERAL INFORMATION:
,nsured’s
Name and Address:
hsuranceCcmpany
Mcy No.:
ADEMCO’S VISTA-50
Other
Type of Alarm:
❑ Burglary
m Fire
❑ Both
Installedby
Serviced by
Name
Name
Address
Address
B. NOTIFIES (Insert B = Burglary, F = Fire)
LocalSoundiig Device
Polii Dept.
FireDe@
Central Station a Name
Ackkesl
!+mrle:
C. POWERED BY: A.C. With Rechargeable Power Supply
D. TESTING:
❑ Quarterly
❑ Monthly
❑ Weekly ❑ Other
continuedonotheraide
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