COVID-19 New York Attestation Form

I am requesting to defer my next installment payment due under my premium finance loan with IPFS of New York, LLC for a period of 60 days, as permitted by an emergency measure recently made by the New York Department of Financial Services.  In connection with my request, I attest as follows:
  1. I am an individual New York resident or a small business.  A small business is defined as a New York resident business that is independently owned and operated and employs 100 or fewer people.
  2. I have suffered a financial hardship that can be demonstrated as a result of the COVID-19 pandemic.
You must provide the following data before we can process your request. If you prefer to print and mail your attestation, click here to download the form, sign and send via USPS mail to: IPFS of New York, LLC, 1055 Broadway, 11th Floor, Kansas City, Missouri, 64105.


Please use the exact name as it appears on your premium finance agreement, billing statement, or other correspondence from IPFS of New York, LLC.

Your account number can be found on your premium finance agreement, billing statement, or other correspondence from IPFS of New York, LLC.

please type your full name

If signing on behalf of a business

*The New York Department of Financial Services has advised that Excess and Surplus Lines policies and policyholders are not eligible for the payment relief as described in the order.