Named Insured as shown on policy
---DC - District of ColumbiaDE - DelawareGA - GeorgiaMD - MarylandNC - North CarolinaNJ - New JerseyPA - PennsylvanniaSC - South CarolinaVA - VirginiaWV - West Virginia
Agency if known
Desired Deferral Start Date
4/1 - April 15/1 - May 1
New Jersey Insureds: Please read our New Jersey COVID-19 Bulletin 20-15.
Type of Relief Requested
---10-Pay PlanExtended Time to Pay Premium
Detailed Reason for Requesting Extra Time to Pay Premium
If Westminster American Insurance Company is providing coverage to you as a landlord, please complete the following:
Is your tenant commercial or residential?
Is any part of your property currently vacant?
---No, no parts of my property are currently vacantYes, part of my property is current vacant
Please specify which units are vacant, and how and when they became vacant:
Prior to submitting this form, please read these important notices:
WARNING: Insureds and Claimants in Delaware
Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
WARNING: Insureds and Claimants in West Virginia
Any person who knowingly presents a false, or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
WARNING: Insureds and Claimants in Virginia
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
WARNING: Insureds and Claimants in New Jersey
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
WARNING: Insureds and Claimants in Maryland and Washington, DC
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
WARNING: Insureds and Claimants in North Carolina, South Carolina, Georgia, and Pennsylvania
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects that person to criminal and civil penalties.
Name of Person Submitting Form
Email of Person Submitting Form if different than above
Relationship to Insured e.g. Owner, President, CFO, Agent, etc.
I have read and understood the disclaimers and information above and agree that all information provided on this form is truthful and accurate.