IMPORTANT NOTICE: Use of this form to make payment by credit card is permitted only on active insurance policies. If you have received a non-payment cancellation notice, you may use this form to make a credit card payment only if the payment is made before the cancellation date stated on the notice. If you have received a cancellation or non-renewal notice which states any reason other than non-payment, do not use this form to make a credit card payment. Doing so will not reinstate or renew your policy. If you have received a cancellation or non-renewal notice stating a reason other than non-payment, and you wish to apply for renewal or reinstatement of your policy, you should instead call our customer service department at 516-681-9400.

I affirm that the insurance policy for which I am making payment is active, and that I have not received a cancellation or non-renewal notice; or, that the insurance policy for which I am making payment is subject to a non-payment cancellation notice, but that the within payment is being made before the effective date of the cancellation. I acknowledge that if I use this form to make payment for an insurance policy which has been cancelled or non-renewed, or a payment made after the effective date of a non-payment cancellation, my payment will not reinstate or renew the policy.