Intact Insurance Company
Name of Insured / Policy Number
Address of Insured / Date
Broker Name / Broker Code
Installation
Name of Installer of Alarm System:
Name of Alarm Monitoring Company:
Are the alarm components ULC Listed? Yes No Is the Alarm Monitoring Station ULC Listed? Yes No
Is the Alarm Installer ULC Listed? Yes No Number of years installer in business: Date System installed:
Is the alarm system installation ULC Certified? Yes No Certificate Number:
Type of Alarm
Burglar Alarm System Fire/Smoke Alarm System Combination Burglar/Fire Alarm System
Alarm Signal Destination
Local alarm bell/siren Transmission to Monitoring Station Transmission to Central Station
Transmission to 24 hour answering service Other (describe) :
Intrusion Detectors
Contacts on all doors Motion detectors Microwave detectors Contacts on all windows
Photo electronic beams Passive infrared detectors Ultrasonic detectors
Other (describe):
Premises Alarm System Warranty Endorsement
Premises Alarm System Warranty Endorsement
For premium credit, we acknowledge the installation of an alarm system, approved by us, at the location for which an alarm discount is shown on the Coverage Summary. You agree to maintain this system in working order and in the “on” position when the dwelling is unoccupied. You also agree to notify us promptly of any change made to the system or if it is removed.
All other conditions, provisions and exclusions of this policy apply.
I have provided personal information in this document and by other means and I may in the future provide further personal information. Some of this personal information may include, but is not limited to, my credit information and claims history. I authorize my broker or insurance company to collect, use and disclose any of this personal information, subject to the law and to my broker’s or insurance company’s policy regarding personal information, for the purposes of communicating with me, assessing my application for insurance and underwriting my policies, renewals, changes of coverage, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf.
Comments
Signature of Applicant/Insured / Date (d/m/y)7139 (03/09)