Honeywell VISTA-40 User Guide - Page 55

Owner's Insurance Premium Credit Request, A. GENERAL INFORMATION - ademco

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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 VISTA-40 Type of Alarm: Burglary Policy No.: Other Fire Both Installed by: Name Serviced by: Name Address Address B. NOTIFIES (Insert B = Burglary, F = Fire) Local Sounding Device Police Dept. Fire Dept. Central Station Name Address: Phone: C. POWERED BY: A.C. With Rechargeable Power Supply D. TESTING: Quarterly Monthly Weekly Other continued on other side - 55 -

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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:
Policy No.:
ADEMCO VISTA-40
Other
Type of Alarm:
Burglary
Fire
Both
Installed by:
Serviced by:
Name
Name
Address
Address
B. NOTIFIES (Insert B = Burglary, F = Fire)
Local Sounding Device
Police Dept.
Fire Dept.
Central Station
Name: _______________________________________________________________________
Address:
Phone:
C. POWERED BY:
A.C. With Rechargeable Power Supply
D. TESTING:
Quarterly
Monthly
Weekly
Other
continued on other side