Capitol Payment Plan New Jersey Payment Deferral Request Form

I hereby certify that (1) I am an individual and am experiencing a financial hardship due to COVID-19, or (2) I am an authorized representative of the business submitting this request form, and the business is experiencing a financial hardship due to COVID-19.  In accordance with the State of New Jersey, Department of Banking and Insurance Bulletin No. 20-17, I am requesting a deferral of the installment payments due under my premium finance agreement as described below.  I understand the payment deferrals do not change the terms of the premium finance agreement nor is this temporary relief a forgiveness of the installment payments.
I am requesting to start the grace period on the date selected below and to defer the installment payments selected below until the end of the grace period.  
Please select the date you would like the grace period to begin.

Please select the specific installment payments you want to defer. You may select up to 3 installment payments.

*Please note that the relief provided by the Department of Banking and Insurance does not apply to: (1) any premium finance agreement accepted after March 1, 2020, or (2) accounts that were not in good standing as of March 1, 2020.  In addition, March installment payments are not eligible for deferral and must be paid or your insurance may be cancelled.

Upon the expiration of the grace period, you may repay the deferred payment in a single installment or under a repayment plan. Please select one of the following options:

*I understand the payment deferrals do not change the terms of the premium finance agreement nor it this temporary relief a forgiveness of the installment payments. I also understand that I will be provided options for the repayment of the deferred payments before the expiration of the selected grace period. 

Please list name as it appears on your premium finance agreements

Your account number can be found on your premium finance agreement, billing statement, or other correspondence from Imperial PFS.

Please type your full name.