Woodhill Green Condo
PAGE 132/134
134/133/21311 21:13 8452977214. ~_j) COMPTROLLER LAnJ IL
~ 6/'-//;1" E - jlJriJ)lJlPA ~ rfo V'/~v-flT-U/-e..,
20l0~Ol-19 JCM
Town of Wappinger
Agreelnent tor the Use of the Town
Hall Facilities for Meetings
FoRI INTERNAL USE ONLY
( ) itizens Room
()6 eeting Room
( ) Other: pecify:
The group is Il! t ex ected to exce~
Date(s):
It should be erstood that group using the Buildings' Facilities for evening meetings must select dates when
Town Meetin j , arc IlurInwly ~\,;he uled (i.e., Just.ice Court.. PlaJllllng Board, etc.) Specia1l'equests will be
considered up their own merit, d arrangements can be m.ade for access to, and closing, the building at the close
of your meetirl .
Received by:
n~te Receiv
Serial #:
~licati
o NotitIed .
Address j
This will contI
noted below:
Chris Masters n 0
Christine Fult n V
S,qe Rose 0
.: l/" /
1!-6 L . ~-~?
~o.o;J&;. of U ' .!i:'Ji" , ',~ 1 v: 1" '~1 J
creatlon (date:o:Jflb '. - . B I Lf" ,J dJ
~-y'. - .4JlfflO"l. -
Agreement rl.r tbe Use of tbe Town Hall Facilities for Meetings' -------- - .tJ.
hill
&::d- dl300
~~n~ No.
{)T-vlD3J-~
being requested for your groups' use of the Wappinger Town Hall Facilities, as
persons
Time: J ()YYl
Yau and your rganization hereb. agree to adhere to the roles set forth on th~ attached page by signature of an
authorized me ber of your Organ.' tion or group.
TIle Town of appinger reserves e right to suspend temporarily this agreement should the Town have need of the
facility for its wn purposes. Advahce notice will be given as soon as possible on such occasions.
The Town Cle should be infonnJd promptly of any schedule change or cancenation of your group activities,
Arrangements or access to specifib area to be used should be made with the Town Clerk at tbe time this form is
submitted.
No applicatio shall be considered approved until it has been submitted to the Town Clerk for review and
Clearance.
9' -/J'-II- 1AI
~'d~Y\\
(/-rJJ.. --II ~
./YI'~ fiW.u >' /.vII. tkt. -i<.uo~ .<>M~ F- Ikoh.. ,
~~ '-1m - ./Yn(kJ~ hi if
cfilmtK ~J--f. ~p~~ ~ ~..
04/03/2011 21:13 8452977214 COMPTROLLER PAGE 03/04
I 2010-01-19 JCM
Terms of the reement must be tctly adhered to by the contracting group as any disregard or abuse of the rules
;~t:~=tl eilities will result I termination of use by the offending group. and they will not be granted
I have read j understand the rulL and regulations for the use of the Facilities in the Town of Wappinger Town
Hall, and will omply with these r~quirem~nls.
Signed:
~
For:
Date: f
Date:
Approved:
Fro..J11:Donn Gerell i Assoc Insurance
9142713598
05/03/2011 15:00
#405 P.003/004
" CERTIFICATE OF LIABILITY INSURANCE I DAlE (MMlDllIYYYYl
05/03/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: Ifthe certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions ofthe 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).
PRODUCER ~
Donn Gerelli Associates Insurance Agency IC No Erl\: 914.271. 6600 I r~~ Nol:914. 271. 3598
1 Croton Point Avenue I i;::MAIL
ADDRESS:
Croton-on-Hudson, NY 10520 CUSTOMER 10':
INSURER(S) AFFORDING COVERAGE NAIC'
INSURED INSURER A : Philadelphia Insurance Co.
Woodhill Green Condominium Association INSURER B : Federal Insurance Co
1668 Route 9 INSURER C :
Building #1, Office INSURER 0 :
Wappingers Falls, NY 12590 INSURER E :
INSURER F :
ACORQ
COVERAGES
CERTIFICATE NUMBER: Town Clerk Office
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 'M-lICH 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. LIMITS SHO\M'.l MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR li'PE OF INSURANCE ~gDL ~~ I /&at~~ I ,tS~~ LIMITS
LTR INSR POLICY NUMBER
GENERAL LIABlLllY PHPK64668 11/0112010 11/01/2011 EACH OCCURRENCE $ 1, 000 I OOC
--,-,--
X COMMERCIAL GENERAL UABILlTY B~~~H YEa~~~ir~enee $ 100,00(
==:=1 CLAIMS-MADE [K] OCCUR MED EXP (Anyone person) $ 5,OO(
A PERSONAL & ADV INJURY $ 1 , 000, OOC
GENERAL AGGREGATE $ 2 I 000 , OOC
m'l AGGREnE LIMIT AnS PER PRODUCTS - COMP/OP AGG $ 2, 000, OOC
X POLICY jf8-r LOC $
AUTOMOBILE LIABl UTY COMBINED ::lNGLE UMIT $
I-- (Ea aCCIdent)
ANY AUTO BODilY INJURY (Per person) $
I--
ALL OWNED AUTOS BODilY INJURY (Per aCCIdent) $
-
SCHEDULED AUTOS PROPERTY DAMAGE
- $
HIRED AUTOS (Per acel dent)
-
NON-OWNED AUTOS $
-
$
UMBRELLA LIAB H OCCUR 79934443 5434~ 11/01/2010 11/01/2011 EACH OCCURRENCE $ 15,000 OO(
10-
EXCESS LIAB CLAI MS- MADE AGGREGATE $ 15,000 OO(
8
~ DEDUCTIBLE $
RETENTION $ 10,00( $
WORKERS COMPENSAllON I T"6~{LrJNs I IOl~-
AND EMPLOYERS' UABIUlY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVED NIA E lEACH ACO DENT $
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH] EL ClSEASE - EA EMPLOYEE $
~~~'c~r~ir~N O't~PERATIONS below E L [l SEASE - POll CY LI MIT $
DESCRlPllON OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remar1<1 Schedulo, If morolIPacoII required)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POUCY PROVISIONS.
Dutchess County AUTHORIZED REPRESENTATIVE ..... i:
Town Clerk's Office
20 Middlebush Road ~,:" ".:.,
Wa~pinger Falls, NY 12590 Alana Jessie/AMJ
CERTIFICATE HOLDER
CANCELLATION
ACORD 25 (2009/09)
@) 1988.2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Frorn;Donn Gerel I i Assoc Insurance
9142713598
05/03/2011 15:00
#405 P.001/004
05/03/2011
Additional Coverages and Factors
Line of Business Coverages for
Coverage
General Aggregate
Products/Completed Ops
Aggregate
Personal & Advertising
Injury
Each Occur rence
Fi re Damage
Medical Expense
Hired Automobile Liability
Non Owned Automobile
Liability
Herbicide & Pesticide
Applicator Coverage
Misc Info:
General Liability
Limits
2,000,000
2,000,000
1,000,000
1,000,000
100,000
5,000
1,000,000
1,000,000
1,000,000
Oed/Oed Type
Rate
Premium
Factor
Basis: Per Claim
CG 2264 07.98
5,000
From~Donn Gerell i Assoc Insurance
9142713598
05/03/2011 15:00
#405 P.002/004
ACORQM
AGENCY CUSTOMER ID:
LOC#:
AGENCY NAMED INSURED
Donn Gerelli Associates Insurance Agency Woodhill Green Condominium Association
POLICY NUMBER Building #1, Office
Wappingers Falls, NY 12590
CARRIER I NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS SCHEDULE
Page
of
ADDIl10NAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM.
FORM NUMBER: 25 FORM TITLE: ACORD Certi ficate of L iabil itv Insurance
Garage Liability
INSR ADD'L
L TR INSRD
POLICY NUMBER
POLICY EFFECTIVE POUCY EXPIRATION
DATE (MMlDDIYYJ DATE (MMlDDIYYJ
UMITS
AUTO ONLY - EA ACCI DENT $
EA ACC $
OTHER THAN
AUTO ONLY
AGG $
ANY AUTO
Automobile Liability
INSR ADD'L
LTR INSRD
POLICY NUMBER
POLICY EFFECTIVE POUCY EXPIRATION
DATE (MMlDDIYYJ DATE (MMIDllIYYl
Excess/Umbrella Liability
INSR ADD'L
L TR INSRD
B
POLICY NUMBER
POUCY EFFECTIVE POUCY EXPIRATION
DATE (MMlDDIYYJ DATE (MMlDllIYYl
UMITS
$
Other Liability
INSR
LTR
POLICY NUMBER
POUCY EFFECTIVE POUCY EXPIRATION
DATE (MMlDDIYYJ DATE (MMlDDIYYJ
LIMITS
ACORD 101 (2008/01)
IS) 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
_New York State Insurance Fund
Workers' Compensation & Disability Benefits Specialists Since 1914
1 WATERVLlET AVENUE ALBANY, NEW YORK 12206-1649
Phone: (518) 437-6400
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
^ ^ ^ ^ ^ ^ 202018424
WOODHILL GREEN CONDOMINIUMS
1668 ROUTE 9
BLDG #1 OFFICE
WAPPINGERS FALLS NY 12590
CERTIFICATE HOLDER
WAPPINGER FALLS TOWN
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGER FALLS NY 12590
POLICYHOLDER
WOODHILL GREEN CONDOMINIUMS
1668 ROUTE 9
BLDG #1 OFFICE
WAPPINGERS FALLS NY 12590
POLICY NUMBER
A 1259 572-4
CERTIFICATE NUMBER
484094
PERIOD COVERED BY THIS CERTIFICATE
07/27/2010 TO 07/27/2011
DATE
4/4/2011
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 1259572-4 UNTIL 07/27/2011, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER
FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL
OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS
OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY.
IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 07/27/2011 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE,
10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE.
NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW
YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER
THE COVERAGE AFFORDED BY THE POLICY.
NEW YORK STATE INSURANCE FUND
~j"()k
DIRECTOR,INSURANCE FUND UNDERWRITING
This certificate can be validated on our web site at https:llwww.nysif.com/certlcertval.asp or by calling (888) 875-5790
VALIDATION NUMBER: 395803651
U-26.3
STATE OF NEW YORK
WORKER'S COMPENSATION BOARD
CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW
PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier
1a. Legal Name and Address of Insured (Use street address only) 1b. Business Telephone Number of Insured
WOODHILL GREEN CONDO ASSOCIATION 914 896 4424
1c. NYS Unemployment Insurance Employer Registration
1668 ROUTE 9 BLDG #1, OFFICE Number of Insured
WAPPINGERS FALLS, NY 12590 8952586
1d. Federal Employer Identification Number of Insured
or Social Security Number
141682740
2. Name and Address of the Entity requesti ng Proof of Coverage 3a. Name of I nsurance Carrier
(Entity being listed as the Certificate HOlder) The First Rehabilitation Life Insurance
Wappinger Falls Town company of America
3b. Policy Number of Entity listed in box "1a":
T own Clerk's Office DBL 133531
20 Middlebush Road 3c. Policy effective period:
Wappinger Falls, New York 12590 07/26/2010 to 07/25/2012
4. Policy covers:
a. lZl All of the employer's employees eligible under the New York Disabil ity Benefits Law
b. 0 Only the following class or classes of the employer's employees:
Under penalty of perjury, I certify that I am an authorized representative or I icensed agent of the insurance carrier referenced
above and that the named insured has NYS Disability Benefits insurance coverage as described above.
Date Signed 4/4/2011 By lPJJa <<If
(Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier)
Telephone Number 516-829-8100 Title Chief Executive Officer
IMPORTANT: If box "4a" is checked. and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent
of that carrier, this certificate is COMPLETE. Mail it directly to the certificate holder.
If box "4b" is checked, this certificate is NOT COMPLETE for the purposes of Section 220, Subd. 8 of the Disability Benefits Law.
It must be mailed for completion to the Worker's Compensation Board, DB Plans Acceptance Unit, 20 Park Street, Albany. NY 12207.
PART 2. To be completed by NYS Worker's Compensation Board (Only if box "4b" of Part 1 has been checked)
State of New York
Worker's Compensation Board
According to information maintained by the NYS Worker's Compensation Board. the above-named employer has complied with the NYS
Disability Benefits Law with respect to all of his/her employees.
Date Signed By
(Signature of NYS Worker's Compensation Board Employee)
Telephone Number Title
Please Note: Only insurance carriers licensed to write NYS 0 isabi I ity Benefits insurance pol icies and NYS Licensed I nsurance Agents of
those insurance carriers are authorized to issue Form DB-120.1. I nsurance brokers are NOT authorized to issue this form.
DB-120.1 (5-06)
....
ir----=-~-:'-:::..:.:..:...m~~~~~...-.~>~~?~.:~~~- ..<..~",' __c_~.;..>~; - -_ - ,"m~_~~
1\ WOODHILL GREEN CONDO ASSOCIATION
~~I 1668 ROUTE 9, BLDG. 1 OFFICE
.' WAPPINGERS FALLS, NY 12590
i DATE 'i <+.gj \1
'I.' PAY \-1 _' I
i b~~~~ OF _1Q-vV) o-t WC<..{:p I Y\ ~\) I $ IcD CO
:! ~ h l ,\,Vl ri \-.eJ a Vl () ) liD DOLLARS Iil
~ . n> ~~~Z\,~ 4~i!E/-
~' FOR-'f\f\ Q ~d/lS ' I - V~ - -- -' -- -
'~' II- 0 0 5 g L. 5 II- I: 0 2 2 0 0 DOL. b I: I. 2 I. 2 ~ 2 5 L. L. b II-
"",.." , ---- ~ - , ..-, - ~- -~y--- . """, -1
5945 ~'II,
"I
I,::
10.4.220 ' I
'I
"~I
111\
I~:
1:~,i~1
1'1
\'i
i-1',
','
!.il
M' i,~i
~I
:~11
b'"C"",=_.=;"~~"".,;,;"~...~-"""",..,,...t,C.--i=',",, ~~~="i.. oV..,,,s.c'''''''--'''''' """',c;~",~.....",~-_.=-~,","" " ",,,,," .,'...-tiC" "',,"" '"i="''''='''"'''''.L=~J;
.
Town of Wappinger
20 Middlebush Rd
Wappingers Falls, NY 12590
(845) 297-5771
RECEIPT
#42866
05/04/2011
Condo, Wood hill Green
1668 Route 9
Ck # 5945
Received $ 100.00 for Building Use Fee, on 05/04/2011. Thank you for stopping by the Town
Clerk's office.
As always, it is our pleasure to serve you.
John C. Masterson
Town Clerk