REQUEST FOR PAYMENT EXTENSION UNDER

California Department of Insurance

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 26, 2020 be paid over an extended period ending October 26.

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

CERTIFICATION / AFFIRMATION