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: April Monthly Payment May Monthly Payment June Monthly Payment Reinstatement Payment Renewal Down Payment Insurance Company: * Choose companyAmerican Transit Ins. Co.American Transit Risk Management ServicesAtic Security, Inc.Atlantic Casualty Insurance Co.General Star Indemnity Co.Global Liberty Ins. Co.Hereford Ins. Co.JMI Associates Ltd.Kingstone Ins. Co.Maya Assurance Co.Transit General Ins. Co. Policy Number: * Your policy number can be found on your FH1. Finance Company (if financed): Choose companyStrand Insurance Finance CompanyKings Premium Service Finance Agreement Number (if financed): Your finance agreement number can be found on your finance agreement. Insured Name: * Please use the exact name as it appears on your insurance policy. Insured Address: * Preferred Email: * In connection with my request, I attest as follows: * 1. I am an individual New York resident or a small business. A small business is defined as a New York resident business that is independently owned and operated and employs 100 or fewer people. Attestation 2 * 2. I SWEAR OR AFFIRM UNDER PENALTY OF PERJURY TO HAVING EXPERIENCED FINANCIAL HARDSHIP AS A RESULT OF THE COVID-19 PANDEMIC. Attestation 3 * 3. I understand that this will create a balance, and I am responsible to pay it off as soon as instructed by the above company according to the payment plan established by the company under the provisions shown by NY DFS Executive Order 202.13. Electronic Signature * signature keyboard Clear Please type you full name Signature Date: * Title: If signing on behalf of a business. SUBMIT
