Skip to main content

NY COVID-19 Payment Accommodation Written Attestation – For Notice Letter Concerning Executive Order and Related Regulations

*indicates required field

Please enter your name
Please enter a valid email address.
Please enter your policy number
Please enter your street address
Please enter your city.
Select a valid state
Please enter your ZIP Code
To submit the form, you must check the box affirming under penalty of perjury that you are experiencing financial hardship as a result of the COVID-19 pandemic.

By clicking “Submit” below, you agree to the following: