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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:
FA130CP/FA130CPSIA
Type of Alarm:
Burglary
Installed by:
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
___________________________Other
Name
Police Dept.
Monthly
continued on other side
Policy No.:
Fire
Serviced by:
Weekly
Other
Both
Name
Address
Fire Dept.
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