Pursuant to 11 NYCRR 229

The brokerage listed herein is the broker of record (the “Broker”) for the Named Insured listed herein. By submitting this form, I attest that a legal representative of the Named Insured has submitted a valid written request for payment extension pursuant to 11 NYCRR 229.

Further, I acknowledge that it is the Broker’s responsibility to make payment extension arrangements with the Named Insured in accordance with 11 NYCRR 229 and any other applicable New York laws and regulations. To that end, the Broker agrees to share the arrangement it makes with the Named Insured with Hiscox Insurance Company Inc. (“Hiscox”), and to work with Hiscox to remit the amounts collected, less commissions earned, per instructions to be provided by Hiscox.