Governmental Insurance Disclosure Statement 2014Governmental Disclosure
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GOVERNMENTAL INSURANCE DISCLOSURE STATEMENT
FOR USE ON AND AFTER DECEMBER 31, 1979
Town Of Wappinger
20 Middlebush Road
Wappingers Falls, NY 12590
Pursuant to 11 NYCRR 29.5 (Regulation 87) the undersigned hereby affirms, under the
penalties of perjury, that the statements made hereinafter are true.
Filed By:
Name: LoVullo Associates Inc.
Address: 6450 Transit Rd Depew NY 14043
1. Name of governmental unit (including county) which ordered insurance services and/or
coverages:
Town Of Wa in er
Coun Dutchess
2. Name and office address (inc;iudir~ county) of person who placed fhe order for
insurance services or coverages:
Marshall & Sterling Inc
1289 Rte 9 #7B Wappingers Falls Dutchess NY 12590
3. Will you share any fees or commissions received on account of business listed in item 1
with any other licensee(s) or other person(s), directly or indirectly?
® Yes ^ No
4. Are you a public officer or party officer?
^ Yes ® No
If you answered "No" to items 3 and 4, you are not required to complete the remaining
applicable items, and you must sign and date the form where indicated and mail it to the
address indicated below.
If you answered "Yes" to items 3 or 4, you are required to complete the remaining
applicable items, and you must sign and date the form where indicated and mail it to the
address indicated below.
RECEIVED
MAR 2 5 2014
pIRE INSPEC1oR
,roWN np wgpPINGER
Governmental Disclosure
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5. Name(s) and address(es) of licensees or others to whom you paid fees and/or
commissions:
Marshall & Sterling Inc
1289 Rte 9 #7B
Wappingers Falls NY 12590
6. The dollar amount you paid to each licensee or other person:
621.75
7. The services rendered by the persons listed in item 5 for which a share of commissions
were paid:
Insurance Services
8. Schedule of coverages placed on account of which fees or commissions were paid to
the persons listed in item 5:
Name of Insurer: US liability Insurance Company
POIICy #: CP1563131A
9. Services rendered on account of which fees were paid to the person listed in item 5:
Placement of Insurance
10. What public office or party office do you hold?
None
Date: 03/18/2014 lJ
Signature: ""~~
Type name of person whose signature appears above: Leonard T. I_oyullo
Telephone Number: (716) s56-3os5
Mail the original disclosure statement to:
New York State Department of Financial Services
Licensing Bureau
Governmental Insurance Disclosure Unit
One Commerce Plaza - 20th Floor
Albany, NY 12257
Mail a copy of the disclosure statement to the most senior official of the governmental unit
which ordered the insurance services or coverages listed thereon.