NYPIUA E-Delivery Service

SUBMIT E-MAIL ADDRESS
To take full advantage of the services provided by the NYPIUA E-Delivery Service, complete this form to be added to our e-mail directory.

Insured Name:

Policy Number: -
E-Mail Address:
Confirm E-Mail Address:
Telephone Number: - -


INSURED'S  ELECTRONIC  SIGNATURE:

 *** 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.  

  

*** PLEASE TYPE YOUR NAME:  
   LAST 4 DIGITS OF SOCIAL SECURITY #: