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Owner’s Insurance Premium Credit Requested
This form should be completed and forwarded to your homeowner’s insurance
carrier for possible premium credit.
This control is UL Listed for: UL Grade A Household Burglary
UL Household Fire
A.  General Information:
Insured’s Name and Address
Insurance Co.
Policy No:
Moose Security System
Type of Alarm:
Burglary
 Fire
         Both
Installed by:
Serviced by:
B.  Notifies (Insert  B=Burglary,  F=Fire)
Local Sounding Device:
Police Dept.
Fire Dept.:
Central Station:
Name and Address:
C.  Powered By:
A.C. With Rechargeable Power Supply
D.  Testing
  
Quarterly
  Monthly
  Weekly            Other
(Continued on Reverse)