Statement of Financial Hardship

COVID-19 (Coronavirus) Attestation Form

COVID-19 Attestation Form
I am requesting to defer the following payment(s) due under my insurance policy with the company marked below for a period of 60 days, as permitted by an emergency measure recently made by the New York Department of Financial Services.

Please check all that apply:
Your policy number can be found on your FH1.
Your finance agreement number can be found on your finance agreement.
Please use the exact name as it appears on your insurance policy.
In connection with my request, I attest as follows: *
Attestation 2 *
Attestation 3 *
Please type you full name
If signing on behalf of a business.