The Customer presenting ADT with this ORIGINAL CERTIFICATE will be eligible to receive a reimbursement of up to five hundred dollars ($500.00) of Customer’s homeowner’s insurance deductible (if any) if, and only if, ALL of the following requirements are met to ADT’s reasonable satisfaction: (i) the property loss was the result of a burglary that took place while Customer’s ADT security system was in good working order and was “on,” and while all of Customer’s doors and windows were locked; and (ii) the intruder entered the residence through a door, window or other area equipped with an ADT detection device, and such detection device was not “bypassed;” and (iii) Customer is not in any way in default under the ADT Residential Systems Customer’s Order; and (iv) Customer files a written claim with their homeowner’s insurance company, and such claim is not rejected or otherwise contested by the insurer; and (v) Customer reports the burglary loss to the appropriate police department and obtains a written police report; and (vi) Customer provides ADT with copies of the insurance claim report, the police report within sixty (60) days of the property loss and proof of settlement by insurance carrier; and (vii) Customer certifies in writing to ADT (by signing this ORIGINAL CERTIFICATE and presenting it to ADT within sixty (60) days of the property loss) that all of the foregoing requirements have been satisfied. Customer understands that presentation of this ORIGINAL CERTIFICATE signed by Customer is required and understands that ADT reserves the right to reject any application for reimbursement that does not comply with ALL of the requirements. Photocopies or other reproductions of this Certificate will NOT be accepted. By signing below, Customer certifies to ADT that all of the foregoing requirements have been satisfied.
Signature: _________________________________________ Print Street Address: ________________________________
Print Name: ________________________________________ Print City, State, Zip: ________________________________
Print Telephone Number: ___________________________
ADT license numbers available at www.adt.com or 1-800-ADT-ASAP®.