REQUEST FOR PAYMENT EXTENSION UNDER DISTRICT OF COLUMBIA DEPARTMENT OF INSURANCE, SECURITIES AND BANKING COMMISSIONER'S ORDER 03-2020| Hiscox Insurance

REQUEST FOR PAYMENT EXTENSION UNDER
DISTRICT OF COLUMBIA DEPARTMENT OF
INSURANCE, SECURITIES AND BANKING
COMMISSIONER'S ORDER 03-2020

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 April 27, 2020 and December 31, 2020 be paid over a period of 12 months beginning on February 1, 2021.

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

CERTIFICATION / AFFIRMATION

Policy Number: *

Named Insured/Business Name:

Primary Business Location: *

Policyholder First Name:

Policyholder Last Name:

Phone Number *

Email Address: *