I certify that the information I have provided in this
E-Delivery Service request is
true and correct. I further certify that by inputting my name and the
last four digits of my social security number in the appropriate spaces on this web
page, I validate this E-Delivery Service request with an electronic signature unique to
me. I agree that signing this E-Delivery Service request with my electronic signature
has the same validity and effect as signing this E-Delivery Service request by my hand
in ink. I authorize New York Property Insurance Underwriting Association
to verify any information included in this E-Delivery Service request.
I understand and agree that by clicking the SUBMIT button on this
web page, I am transferring my E-Delivery Service request to New York
Property Insurance Underwriting Association using the internet and I
acknowledge and agree that New York Property Insurance Underwriting
Association is thus unable to guarantee the privacy and confidentiality of
this electronic E-Delivery Service request. I agree that, regardless of the type of
security features used to facilitate the submission of this electronic
E-Delivery Service request, New York Property Insurance Underwriting Association will not be
held liable for the interception, transmission failure or other misuse of this
electronic E-Delivery Service request.
If you do not agree to the terms above, you may submit a paper version of
this E-Delivery Service request by mail or fax. For more information,
contact New York Property
Insurance Underwriting Association at 212-208-9700.