11
2010-01-19 JCM
Serial #:
Chris Masterson 0
Christine Fulton .~
Sue Rose 00
DliJ /d3 k5lO I
\ \
Town of Wappinger
Agreement for the Use of the Town
Hall Facilities for Meetings
FOR INTERNAL USE ONLY
Received by:
Date Received:
~Application ~100.00 :ft:rt.ofLI
~otified Recreation (date: Uid-~ )
Agreement for the Use of the Town Hall Facilities for Meetings
mon-+c.hiA f{9lDnhw~ (QYdCYnin1u'(Yl'
Name of Organization or Group
Name of person representing the Organization or Group
Phone No.
Address
This will confirm the arrangements being requested for your groups' use ofthe Wappinger Town Hall Facilities, as
noted below:
( )
W
( )
Senior Citizens Room
Large Meeting Room
Other: Specify:
~M-+{lcJ1td
The group is not expected to exceed
Date(s):
persons
Time:
It should be understood that groups using the Buildings' Facilities for evening meetings must select dates when
Town Meetings are normally scheduled (i.e., Justice Court, Planning Board, etc.) Special requests will be
considered upon their own merit, and arrangements can be made for access to, and closing, the building at the close
of your meeting.
You and your Organization hereby agree to adhere to the rules set forth on the attached page by signature of an
authorized member of your Organization or group.
The Town of Wappinger reserves the right to suspend temporarily this agreement should the Town have need of the
facility for its own purposes. Advance notice will be given as soon as possible on such occasions.
The Town Clerk should be informed promptly of any schedule change or cancellation of your group activities.
Arrangements for access to specific area to be used should be made with the Town Clerk at the time this form is
submitted.
No application shall be considered approved until it has been submitted to the Town Clerk for review and
Clearance.
-
-
TOWN &COUNTRY
PROPERTY MANAGEMENT
June 22, 2010
Mr. Christopher Masterson
Town Clerk - Town of Wappinger
20 Middlebush Road
Wappingers Falls, NY 12590
Re: Montclair Townhouse Condominium
Annual Homeowners' Meeting - October 27, 2010
Dear Mr. Masterson,
Enclosed please find the following pertaining to the reservation of the large meeting room at the
Town of Wappinger Town Hall on Wednesday, October 2ih, 2010, 6:00pm to 1 0:00pm for the
Montclair Annual Homeowners' meeting:
. Signed Agreement for the use of the Town Hall facilities
. Certificate of Insurance noting the Town of Wappinger as an Additional Insured
. Check No. 1535 of Montclair Townhouse Condo payable to the Town of Wappinger in the
amount of $100.00
Thank you for your assistance in this matter.
mrulY yours
Yeg;;tdbe
Town & Country Property Management, Inc.
Managing Agent
Montclair Townhouse Condominium
fRi~~~DW~{Q)
JUN 232010
TOWN OF W
TOW APPINGER
N CLERK
Ips
Enclosures
3 Neptune Road, Suite A19A. Poughkeepsie. NY 12601 tel. 845.462.2270 fax 845.462.2272
e-mail townandcountrypropertymgmt@att.net
~
Received:
2/27/09
5: 11 PM;
( tl40' ,~O - '''' '"
FEB-27:2009 01:42P FRoM:ToWN CLERK
(845)298-1478
TO: 4622272
P.2
"
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TOWN OF WAPPINGER
P.O. Box 324 - 20 MIDDLEBU
W APPINGERS FALLS. NY 1 259
Town Clerk
Office: 845.297.5771 ... Fax: 845.297.
www.townofwappinger.us
fR1~CG~UW~[Q)
JUN 2 3 2010
TOWN OF WAPPINGER
TOWN CLERK
t For The Use Of The Town Hall Facilities For Meetings
t'lS: l.j h;/~J-7tJ
Phone No.
This will confirm the arrangements being requested for your groups' use of the Wappinger Town Hall
Facilities, as noted below:
( ~ / Senior Citizens Room
(\y Large Meeting Room
() Other: Specify:
The group is not expected to ~xceed -5 0 persons /
Date(s): U)2-dAJe.5df}~. OCA~b~' J., 1.),OJI) Time: (I) .:l-tJf(l1
It should be understood that groups using the Buildings' Facilities for evening meetings must select
dates when Town Meetings are normally scheduled (i.e., Justice Court, Planning Board, etc.) Special
requests will be considered upon their own merit, and arrangements can be made for access to, and
closing, the building at the close of your meeting.
You and your Organization hereby agree to adhere to the rules set forth on the attached page by
signature of an authorized member of your Organization or group.
The Town of Wappinger reserves the right to suspend temporarily this agreement should the Town
have need of the facility for its own purposes. Advance notice will be given as soon as possible on
such occasions.
The Town Clerk should be informed promptly of any schedule change or cancellation of your group
activities. Arrangements for access to specific area to be used should be made with the Town Clerk
at the time this form Is submitted.
No application shall be considered approved until it has been submitted to the Town Clerk for review
and clearance.
Terms of this agreement must be strictly adhered to by the contracting group as any disregard or
abuse of the rules for use of the facilities will result in termination of use by the offending group, and
they will not be granted reinstatement.
TOW04S.TC.THF (4~3 Rev) I of3
Received: 2/27/09 5:12PM; (845)298-1471:3
_> IUWII Ot VUUII'-IY 11_t-"'........3 '''=''''-~
~ES-27...2009 01:42P FROM:TOWN CLERK
(845)298-1478
TO: 4622272
P.3
Town of Wappinger Town Clerk
Agreement for the use of the Town Hall Facilities for Meetings
I have read and understand the rules and regulations for the use of the Facilities in the Town of
wappinger Town Hall, and will comply with these requirements.
Signed~~ -
For: (J~
(Name of Group or Organization)
Date:
~/~/j~j~
r:f(x-e:---,
n T~F~11'o
Dated:
Approved:
TOW045.TC-IHF (4-0) Rev) 2 of)
Il"==''--'''=='..LV''='U.
01 IU/ IU b:3BPM;
9142713596 -> Town & Country Property Mgmt;
Page 2
From:Donn Gerell Assoc Insurance
9142713598
06/10/2010 13:58
#911 P.002/007
ACORQ. CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlOOIYYYY)
06/10/2010
PRODUCER 914.271.6600 FAX 914.271. 3598 nus CERllFICATE IS ISSUED AS A MATTER OF INFORMAll0N
Donn Gerelli Associates Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERllFICATE
HOLDER. THIS CERllFICATE DOES NOT AMEND, EXTEND OR
1 Croton Point Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Croton-on-Hudson, NY 10520
INSURERS AFFORDING COVERAGE NAlC #
INSlRED Montclair Townhouse CondominiLIII INSURER A Great American E&S Insurance
c/o Town & Country Prop Mgmt INSURER B Zurich Insurance Company
3 Neptune Road, Ste A19A INSURER C State Insurance Fund
Poughkeepsie, NY 12601 INSURER D
I INSURER E
COVERAGES
THE POLICIES OF NSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I~~~~ TYPE OF INSl.RANCE POLICY NUMBER 62-N~~FM~ b~fl:c~Wbb~ LIMITS
I ~NERAL LIABILITY PAC8782218 10/01/2009 10/01/2010 EAQ-I OCCURRENCE $ 1,000,00
I X COMMEROAL GENERAL L1ABLlTY PREMISEs IE~t:o~~~r~encel $ 250,000
, = :=J CLAIMS MADE 00 OCCUR
MED EXP (Anyone person) $ 10,00
A PERSONAL & ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,00
! GENt AGGREGATE LIMIT APPLIES PER PROruCTS - COMP/OP AGG $ 2,000,00
Xl POLICY -n jg8-r n LOC
~OMOBlLE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Ea aCCIdent)
-
ALL OW NED AUTOS BODILY INJURY
- $
SQ-IEruLED AUTOS (Per person)
-
HIRED AUTOS BODILY INJURY
- (Per ac Cldent) $
- NON-OWNED AUTOS
- PROPERTY DAMAGE $
(Per ac Cldent)
GARAGE LIABILITY AUTO ONLY - EA ACODENT $
~.ANY AUTO OTHER Tl-IAN EA ACC $
AUTO ONLY AGG $
EXCESS I UMBRELLA LIABILITY EAQ-I OCCURRENCE $
:=J OCCUR D CLAIMS MADE AGGREGATE $
B $
~ DEDUCTIBLE $
,
RETENTION $ $
WORKERS COMPENSAllON I T'O~l L~Hs I IU~R-
AND EMPLOYERS" LIABILITY Y/N
C ANY PROPRIETORlPARTNERiEXECUTlVED E L EACH ACCIDENT $
OFRCERlMEMBER EXCLUDED?
(Mald.tory in NH) E L DISEASE - EA EMPLOYE $
If yes, descnbe under E L DISEASE. POLICY LIMIT
SPEOAL PROVISONS below $
OTl-ER
DESCRlPllON OF OPERATIONS f LOCAllONS I VBiICLES I EXCLUSIONS ADDED BY ENooRSEMENT f SPECIAl. PROIIISIONS
Certificate Holder is included as Additional Insured.
CERllFICATE HOLDER
CANCEL LAll ON
SHOULD ANY OF Tl-IE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Tl-IE EXPIRAllON
DATE Tl-EREOF, Tl-IE ISSUING INSURER WILL ENDEAIIOR TO MAIL ~ DAYS WRITTEN
NOllCE TO Tl-IE CERllFICATE HOLDER NAMED TO TI-E LEFT, BUT FAILURE TO 00 SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSlRER, ITS AGEI'lTS OR
Town of Wappingers REPRESENTATIVES.
20 Meadowbush Road AUTl-IORlZED REPRESENTATIVE (~'...:- I-l"r.1Jc.
WaRpinger Falls, NY 12590 Claire McGranaqhan/RCP
ACORD 25 (2009/01)
@) 1988-2009 ACORD CORPORAll0N. All rlgl"ts reserved.
The ACORD name and logo are registered marks of ACORD
Repeiveq: 6/10/10 5:39PM;
9142713598 -> Town & Country Property Mgmt; Page 3
From:Donn Gerell i Assoc Insurance
9142713598
06/10/2010 13:58
#911 P.003/007
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized
representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,
extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2009/01)
Receivea: 6/10/10 5:39PM;
9142713598 -> Town & coun-cry ....r-uf-'... ~y ,.,"'...~,
Frorn:Donn Gerell i Assoc Insurance
9142713598
06/10/2010 13:59
#911 P.004/007
06/10/2010
Additional Coverages and Factors
General Liability
Line of Business Coverages for
Coverage
General Aggregate
Products/Completed Ops
Aggregate
Personal & Advertising
Injury
Each Occurrence
Fi re Damage
Medi ca 1 Expense
Hired and Non-Owned
Volunteers as Insureds
Employee Benefits
Oed/Oed Type
Rate
Premillll
Factor
Limits
2,000,000
2,000,000
1,000,000
1,000,000
250,000
10,000
1,000,000
1,000,000
Workers Compensation
Line of Business Coverages for
Oed/Oed Type
Rate Premillll Factor
200.00
52.32
143.34 6.30000
-740.96 0.25000
Coverage Limits
WC & Employer's liability 100,000/500,000/
100,000
Expense constant
Terrorism
SIF Differential
Surcharges
Premium discount
Reeeive~: 6/10/10 5:39PM;
9142713598 -> Town 8< l,;ounl:ry rl~ul-'~'"Y
, F.rorn:Donn Gerell i Assoc Insurance
9142713598
06/10/2010 13:59
#911 P.005/007
.. .... ..New York State . Insurance Fund
. W orkers'C'ompiilSation & .DisubilityBiitejits SpeeWisv, Since 19J4
199 CHURCH STREET; NEW YORK.N,Y, 10007.1100
FhOne:(B88)9&7 ~
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
^ "" ^i!.1\
MONTCLAIR TOWNHOUSESCONOO ASSOC
% TOWN & COUNTRY PROPERTY MGMT
3 NEPTUNE ROADCSUITE AlgA
POUGHKEEPSIE NY 12601
(poLicYt4bLDE.R............n............m.................................000..............[ j'ce'RTiFICATE' HOLOER.................................................m.........I:.::
. MONTCLAIR TOWNHOUSES CONDO ASSOC : ~ TOWN OFWAPPlNGERS
0/0 TOWN & COUNTRY PROPERTYMGMT . 120 MIDDlEBUSH RD
3 NEPTUNE ROAD-SUlTEA19A WAPPINGERSFAlLS NY 12590 !
POUGHI<EEPSI[ NY 12601
: : 1 :
i...............m...m..mnnm..m...m..m......'..n'n..............m................._.........! L..m.'..'........... .......... ........'...000...................000.....'...........000......000....;
: POUCYNUMBER : CERTIFlCATE.NUMBER .T...PERioci:COVERE.O.By.TH.isnCERTiFICATEm....nr.nnOATEmn..00;
; G121770&-9 .130994 . 03/29f2010";'Q 03/29/2011 : 6/10i2010i
1...........00.........................................................................000................................................~._.......__............._.........................................m.....~
'[!-l:$ is TO CERTlI'" fliAT THE PQUCYHOLQER NAMED A60VE 1$ INSURED WJ1"H TIlE .NEW YORK $TATEINSVAANCE
FUND UNDER POLICY NO. 1217706-'9 UNTIL. 0312912011. COVERING THE ENTIRE OBUGATION OF THIS POLICYHOLDER
FOR WORKERS' COMPENSATiON UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITtI RESPECT TO ALL
OPERAnONSIN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW
l~ SAID POLICY IS CANCELLED. OR CHANGED PRIOR TO O~I19J20t1 IN SUCH MANNER AS TO AFFECT TI-; IS CERTIFJCATf:.
10 PAYS WRnEN NOTICE OF SUCH CANCELLAtiON wi.LLBE GlVliONTO THE CERTIFICATE HoLDER AeOVE
NOTICE BY REGULAR MAIL SO ADDRESSED SHALL .BE SUFFICIENT COMPLIANCE WITH THIS PROV:S10N. THE NEW
YORK STATE INSURANCE FUND00ES NOT ASSUME ANY LIABILITY N THE EVENT OF FAILURE TO G:VE SUCH NOTICE.
THIS CERTIfICATE IS ISSUED AS A MATTER Of INFQRMATIONONLY AND CONFERS NO RrGHTS NOR INSURANCE
COVE.RAGE UPON 1l:iE CEfnlflCATE HOLOE~. THIS CERllFICATE ;JOES NOT AMEND. EXTEND oR ALTER
THE COVERAGE AFFORDED BY THE POLICY
NEW YORK STATE INSURANCE FUND
1~7H~
ClIREC10R.INSURANCE HIND ONO!:RlNRITlNG
Thisceriificalecan be vaiidaledon our web site at httpsJ/www.nysif.comlcertlcerl\lal.aspor bycaHing (SS8}87S.5790
VALIDA nON NUMBER: 845990495
U.26.3
Received: 6/10/10 5:40PM;
9142713598 -> Town & Country t-"rOpt:H-LY l"'I'dIIl~,
F.rom:Donn Gerell i Assoc Insurance
9142713598
06/10/2010 14:00
#911 P.006/007
STATE OF NEW YORK
WORKERS' COMPENSA TION.BOi\RD
CERTtFrCATE OFINStlRAJ'tlCE COVER>\GE UN1J~RTHE NYS DlSAB1LITYRENEFffSLAW
PA.RT 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent oflhat Cartier
la. Legal Namunc Address oflnsured{Uscstreetaddrcs:; ooly) lb. Business n~lepbone Numm:r oflnsured
845-462.2270
MONTCLAIR TOWNHOUSE CONOOMINlUM
ASSOCIATION
1-37 ALPINE VRIVE
WAPPINGERS fALLS. NY 12590
1 c. NYS Unemployment Insurr:JWe Employer
RegJ"str'dtil.)J) Nuro~r oflnsurcd
8341874
Id. FederaiEn1ployer Id~l1tification Number of
lr;sllredor Social S!:CuritY NUtllber
222838233
1. Nmneand Address nftheEntiW Requesting proof af Coverage
(Entity Being Listed as the Certific.ate Holder)
Town ofWappingerl;
20 Meado\\'bush Road
Wappinger Falls, NY 12590
~ Narneoftnsurance Carrier
Zurich. Amencan.InsliranC'e.Company
58Soutb Service RQad, Melville, ]'I,'Y n747
3b. Policy Number of entity listed in box" 1 aM:
1755453 001
3c.. Policy effective period:
1125/2010 To 1/25,/2011
4. Polley coYers:
a, I29 AU of the employer's ernplo)'ceseligibteunder ;he New York DisllhiJityDenefits Law
b. 0 Only thefoUowing dass or closscs of the employer's employees;
Uuuerpcnalty t1fpe~jury. 1 certifythllt J lllI\an authonzeu repcesentaiivcor licens.edagent ofthi1illSUTlUlCecarrietn:ferenced above
lllld (hat the named in,suml hilS NYS Dis'lbility Bencl1ts Insurdllce (;o,,'C;rllgc aStk;,cribt:.d above.
Date Signed ~I~I~?~.~.....
BY..~~~.......
(Sij!.llahue of in.<wanu, rnnkr', "UliJuri/.~ loprcs""t.lm, ur NYS J;ic.m,,:d Insurllm:e AIIl'"tufth.t !n:;,ol1m:" carri.r)
Telephone;; Number J~~..0_~~?_-l~~9...m.
Title Operations Manag:r
IMPORTANT: Ifb"" "da" ,~ ehecked, and this )(1tl11 i~ sig,1Cdhy 0,. insUnJr.::. earri<Of. aulhcri:rzdreprt-$entative or NYS l.icen<ed Insurar.c.e Agent of
!h'l C41Ticr, thlS ocrtifi;;al<; i. CO?'.~PIJ,Tf:.. M.ui it Jircelly 10 ~ ~crtifkatc holder
It bG:< . 4b"i~ checked, this cemficHk i.~ NOT COMPLETE tOlpOrp~ses {Jf ~ti,)u 220. Sued. g <ifthe DJ>llh,\;ty&:neiit<;u'o'l, ltmust be
'n3ih:d for co.'lll'ktiun IOlhe WVfkcrs' C,jllJpeJl~tJQ:: Bo~rd. UB Phtli'-Ao:e\llance Unit. 2(' P~rk St-.:el, AlooflY; New Y6t:< 12107.
PART2. To beCOf1\Dlete<lbvNYS WOrkeJ$' CQmpen$ati()nao~rd (Oi'llvifbox ..4b"l)f Part 1 has peen cheeke<l)
StIlte Of New York
Wocl~ers' CurnpelWltioll Boarn
According to infolTl'latiQnmaintained by the NYS Workers'Compensation B03rd. ~he above-named employer hzs complied willl
the NYS Disability Beneti1S Lit"" with respect to all of his /he I" employees.
DateSigr.ed
By
(Sisn.at= "f ~y S .\IIork.....' C,,""penS8lionl.loard Empluyee)
TeleI>hooi! Number
Title
Pleflse JVou..Q"ly i/1Suyw,/Cecqr,.krs licenstd to write Ni"S disah:i1itybmdil..>r i"wranc.( policies a/!dNYS.licerrsed inyurarrceagcl1{s
qflhoseJnsul'@~'e farriers are 4uthcrized (0 iSHie Pln"m DB-12(),1.. In.5urom:e brokers are NOTaujhorized to issue Ih/sfarln.
DB-120.l (5-06)
Re6e'ivect: 6/10/10 5:41PM;
9142713598 -> Town & Country Property Mgmt; page r
F.rorn:Donn Gerell i Assoc Insurance
9142713598
06/10/2010 14:00
#911 P. 007/007
Additional Instructions for Form. DB-120.]
By ~ignjng this form, the insurancecsrrieridentified in hox *3" on this fonnis certifylngthat iLis insudngthebusiness
referenced in box "I a" tordisab.ilitybenetlts underthe New York State Disabllhy8cllcfitsLaw. The htS\;'llll'lce Carrier ot it~
li::ensco agl;ntwill sltnd this C(rtificate oHnsun:U1ct:cw the entity listed as the ccrtifieateholder in box "2"..This Certificute is
~lalidlortheearlieniffJne.vi!l11'tifter tlJisfott1ris appro~'ed ~r theil'.Ulrance carrier or m/icelf$edtlgent,iJr thepolic.JI
f&.71il'atilmdoulisttdin box "je",
Please Notc: Upon thecancellatioll of thedisahiIity benefits poliey lfldicatedon thisrorm. iithe business tontinues Le be named on a
permit, licemc orCQlliraCt iss.ucd byaccrllf'icalC holder, the business must provide thatccniticatchoillcrwith .1lX:CW CcrtificatcQfNYS
Disability B.enefitsCoverageor other authorized proof thaI tlteousinessis complying Witll the mandatory coverage requirements of the
N~w YorkStat.:: DisabHityfknefitsLaw.
DISABILITY BENEFITS LAW
~220.Subd.8
(a) The head of a state ormul1idpaldepartment, board, commission or office authorizcd. or. required by law
tn issue any pennit for orioconnection with any wQrk involving theemploymentof ernployeesin
employment as defined in this article, and not withstanding any general or special statute requiring Or
authorizing. the issue of such pecrnits, shallnot issue such permit unless proof duly subscribed by an
insurance carrier is produced ina form satisfactory to the chair, thatthe payment of disability benefits for
all employees has been securedasptovided by this article, Nothing herein, nowever, shall be constt'uedas
creating any liability cn the pnrt of such state or municipal department, board, commission or offke to pay
any disability benefitswany suchernployee ifso employed,
(b) The head of a state or municipal department, board; commissionorofficeauthorized or required by Jaw
to enter into ar.y contract for or in connection ,....ith any work involving the employment ofemployees
in employmt--ntasdefinedinthkartklc, and notwithstandlog any general or special statute requiring or
authorizinganysucn contTll-Ct, shall not enter imoany such contract unless proof duly subscribed by an
insurancecatriet is prodllced in a form satisfactory to the chair, that thepnyment of disability benefits for
all employees has been secured as provided by this article.
DB-l20.l (5-06)
.' .
8454622272j
Sent By: Town & Country Property Mgmtj
.~----- --- . -.. ,--.-
From:Donn Gere~li Assoc Insurance
9142713598
ACORlt
Oct-5-10 3:16PMj
Page 2/2
10/05/2010 09:45
IB68 P. 0021 004
CERTIFICATE OF UABIUTY INSURANCE
DAft~"'''''J
10/05/2010
1.. cP'I"IFIC""" lIED AlAIlATTD OF woMtA" OII.VNDtclNFEM NO IIIGtm uPoNT" CEJI'I'FICATE HOLlIER. T"
cP1RCATEDOEINOT......~1M!Ly DR NlGATMlLY _END. ElTIJD OR M.1'IR T1I! ~ AfFotID!D 1Y'nIE POUCES
RLOW. "*.~TlClf~IDOIIlIOTcClMl11lVn..eONTUCTRtWI!INT..--_INII(.)1 ~D
IlEPREI2NTAtM OR PRODUCER. NID MiCllt11ACATE HOUIEIl
IIPCIIn'Mf: If... h......"... ~1ifIUMD."" ~I""''''''''''' llUBROM'IIDM .WAMD....-..
............ _1IlII..,....... '*"',................,.........~ ............. M ----... Mt ---.... fA...
~....... in .....lICII
PtlllIIUCIOI
DoIUl Geu.1l1 ~'Qcj,.t.u IA.ur..~ 1geftcy
1 Cxoton Point Avenue
Croton-on-lu4aoD, IY 10520
....-0
Mont.clair To.~oU" COD4oaiDiua
c/o To_ , Co~t%y hop Mpt
3 .BP~ua. load, St. AltA
Pouqht..p.l., NY 12'01
..,...Il:
. 9U. 2'71. 6600
.914.2'71.3598
IUIIC: .
COVERAGES . . .n NUIIIER: IOWA of .app~9.U REVISION NUMBER:
TI11S IS TO CeRTFYTl4AT THE l'<lLICtsS Of ICSUIWfC6USUO BOW AA\E IlEallSSUEO lOTHE tlSUIliD IWE)MOYiI"()/\ THE PO.CVI"t;lOOO
M)lCATlfD. N01WITHSfNtOltG~A~. TENI OR c;.c)HDlT1ON OF NN~ OR O'f",ER DOCUlotENT WfTH RESPeCT TO WKlCl1 TMS
CERTf'ICA'TE W>.V BE IS$UED Oil....., PERTAIN, 'TIE NSURNlClE AFf<IRDED BY ltolE PQlJC:ES OESCAeEO MEfl&tll$ SUaJECT TO ALL 1lE n:RMS,
EXa.U$lONS MID C(lttI)InlNS OF SUCKl"OLttES. LIlTS SHO'MoIlIAYHA\IIS EN 1iiiJ&
~ T'fK fIII......-ce IIOUf;T - . l.IIl'I
.....lJMI.IIY U0003011l 'W,IIt10 1M1I21U lIIOlClCCUl\NIlCe . 1 OOO,OOC
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