FINANCIAL HARDSHIP AFFIRMATION FOR RELIEF UNDER NEW JERSEY
BULLETIN NO. 20-15

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 1, 2020 and August 1, 2020 be paid over a 12-month period in equal installments to commence no later than August 1, 2020.

To that end, I certify and affirm under the penalties of perjury that the Named Insured is a resident of the State of New Jersey and is currently experiencing financial hardship(s) due to the novel coronavirus (COVID-19) pandemic.

CERTIFICATION / AFFIRMATION