REQUEST FOR PAYMENT EXTENSION UNDER
Oregon Department of Consumer and Business Services Executive Order 20-30

As the owner, officer or authorized representative (“Representative”) of the Named Insured under the policy listed herein (the “Policy”), I request that the payments due but not paid during the period between August 1, 2020 and August 31, 2020 be paid over a period of 60 days.

To that end, I certify and affirm under the penalties of perjury that the Named Insured is a resident of the Oregon.

CERTIFICATION / AFFIRMATION