The URL can be used to link to this page

2011NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SION, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~- TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ....................................... ............................... :~:.:.:.f?C~2iQEi:~EC3V;;R~ti:.$V:.1~Wt~:.C~~I~:FC~~~: ~:.:.:.:.>: ~: ~<: ::::::::::~:~z~~~~>~.~::~~:::~o.:t~:t:f,~dr~ ::::::::::::::::::::::::::: POLICYHOLDER MID HUDSON CONSTRUCTION MANAGEMENT INC 210 NEW HACKENSACK RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1290 038-7 DATE 10/11/2011 CERTIFICATE NUMBER 737-282 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 10/31/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~", Q~~"~ ~o Tp ~~T 14 2011 T~wN CLERK FR CANCELLATION U-26.3 THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING Q51 NEW YORK STAT~~I1E INSURANCE FUND 1 WATERVLIET AVENUE ~518)54~7'6400ANY, NEW YORK 12206-1649 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 •>:•.•P.~Eiff~~/i~`•EEC)ri~I~R~D:~~h':~:1'HIg~•:~C~t~i'i~iP~C~4'tE~:~:~>:~: ~:~: ~:~: ~: POLICYHOLDER MID HUDSON CONSTRUCTION MANAGEMENT INC 210 NEW HACKENSACK RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1290 038-7 DATE 10/11/2011 CERTIFICATE NUMBER 217-846 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 10/31/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~~~~~~~ ~~ $ , ~ ocr 2 ~ zfl~~ TOWN OF WHAprNGER TOwN CLERK CANCELLATION U-26.3 THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 2 ~ ~ c-rnr nn~-~f inn ~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE FXTE~iSION, ALBANY, NEW YORK 12206-1649 (151811 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLE BUSH ROAD WAPPINGERS NY 12590 POLICY NUMBER +A 1412 334-3 DATE 10/06/2011 CERTIFICATE NUMBER 604-754 :~:.::.i?~tic~:;E~rt~REt?:;8~:_:~WI~:.Cti~IF.fG~T.~::.:.}:;:.:.:.::: POLICYHOLDER RBCW CONSTRUCTION CO 198 BASEL RD PINE BUSH INC NY 12566 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLE BUSH ROAD WAPPINGERS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1412 334-3 UNTIL 2/16/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WOR~- ERS' 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 2/16/2012 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 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. (~~C~L~MC~D ~`~ , ~-'' ~""~ .~' ~ .~ OCT ~l 3 2011 TOWN OF WAPPINGER TOWN CLERK THE STATE INSURANCE FUND ~~ IJ-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 663 CERT02-2/2001 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name 8~ Address of Insured (Use street address only) 1b. Business Telephone Number of Insured MCMILLEN BROTHERS INC 221-666-1 (845) 831-1075 20 EAST MAIN STREET BEACON NY 12508 -4 c. NYS Unemploymenttnsurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, i.e., 1d. Federal Employer Identification Number of a Wrap-Up Policy) Insured or Social Security Number 14-1431674 2. Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Federated Mutual Insurance Company TOWN OF WAPPINGER 40 20 MIDDLEBUSH RD 3b. Policy Number of entity listed in box "1 a" WAPPINGERS FALLS NY 12590 9392870 3c. Policy effective period 07/21/2011 to 07/21/2012 3d. The Proprietor, Partners or Executive Officers are: included. (Only check box if alhryartflers/officers included) Q all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "1a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). "The Insurance Carrier or its licensed agent will send this Certificate of Insurance to`fhe entity listed above as the certificate holder in box "2". The Insurance Carrier will also notify the above certificate holder within 1 D days !F a policy is canceled due to nonpayment of premiums or within .30 days IF there are reasons other than nonpayment of premiums- that cancel "the policy or eliminate. the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box " 3c'; whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: ~~ Cove i (Printp~me of authorized representative or licensed agent of insurance carrier) ~~Q(~ /J~~ Approved by: I ~ I(~ /) ,rt' "`/// V .. Signature) (Dat) L~ ~~T Title: ~ . ~~ ~ , 2 4 1011 Telephone Number of authorized representative or licensed agent of insurance carrier: 888 33' -4949 FA~WAPCPDINGER Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers R^ are NOT authorized to issue it. C-105.2 Ed. 09-07 www.wcb.state.ny.us ri ERIE INSURANCE COMPANY OTHER INTEREST COPY Erie Insurance P.O. BOX 1699 ERIE, PA 16530 Company Memher Erie Insurance Group CANCELLATION NOTICE 100 Erie Ins. PI. ~ Erie, PA 16530 MAIL DATE 10/21/11 CANCELLATION EFFECTIVE POLICY NUMBER Q34 5120179 NY 11/22/11 12.01 AM DUE DATE 10/O1/11 POLICY EFFECTIVE DATE 10/O1/11 STANDARD TIME FIVESTAR CONTRACTORS POLICY NAMED INSURED DELUXE CONTRACTING INC AP-00024 TOWN OF WAPPINGERS AQ-00027 3 ELM STREET EXT NN1480 20 MIDDLEBUSH RD NN1480 WAPPINGERS FALLS NY 12590-3736 WAPPINGERS FALLS NY 12590-4004 WE ARE NOTIFYING YOU THAT THE ABOVE POLICY IS CANCELLED AS OF THE CANCELLATION EFFECTIVE HOUR AND DATE SHOWN ABOVE, UNLESS ON OR BEFORE SUCH DATE, THE PREMIUM IS PAID TO US OR OUR AGENT IOR A BROKER AUTHORIZED TO RECEIVE SUCH PAYMENTI. IF WE HAVE BEEN ASKED TO PROTECT OTHER INTERESTS, WE ARE REQUIRED TO ADVISE THEM OF THIS CANCELLATION. THE REASON FOR THIS ACTION: NON-PAYMENT OF PREMIUM A $10.00 LATE FEE HAS BEEN ASSESSED. 00027 NN1480 GERE GERELLI INS AGY INC PHONE 1-845-265-2220 t "U ~~ ~N~F 2~~0 o ~~ c~F ~c R~ FR 9480~C 6/00 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 •:~:~.~R~€i1QF3>EC3\/ER~CS:~BY:~fiWIB:~C~€~TIF:ECaTE~:~>::~:~»: ~:~: ::::::::::z>•z~~~>~:~~:::~~:::~a:fz~~:~~r~ ::::::::::::::::::::::::::: POLICYHOLDER SHANE ALEXANDER DBA ALEXANDER CONSTRUCTION 316 MYERS CORNERS RD WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER POLICY NUMBER +A 1315 132-9 DATE 10/05/2011 CERTIFICATE NUMBER 275-024 TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 10/25/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. /~ ~~ ~.~ ... . - . .. - ,. _- ~:~ ;, '~ ~_''~>> OCT ~ ~~ 20th ~' ..._ CANCELLATION THE STATE INS ~~~ R U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE FXTE~TSION, ALBANY, NEW YORK 12206-1649 (151811 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH RD ATTN: MARIA WAPPINGERS FALLS NY 12590 .:.:,p~ticta:.EC3.rr~R~d:.8~1:.1~Wi~:.E~E~1'IRECQ'~~:5 :.:.:::.:::.::: POLICYHOLDER JEFFREY BUCCIERO DBA HUDSON VALLEY RENOVATIONS 184 SMITHTOWN RD FISHRILL NY 12524 NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 10/23/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~ CANCELLATION U-26.3 POLICY NUMBER *A 1324 085-8 DATE 10/03/2011 CERTIFICATE NUMBER 137-630 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD ATTN: MARIA WAPPINGERS FALLS ~~ ~~D .. ,£ o ~~0 ~._~ ~ T N OF s ~o// ~l~/N ~~9pprN C~~cRkcFR l THE STATE INSU~fRANCE ~} DIRECTOR, INSURANCE FUND UNDERWRITING 541 cTnreni-~ inn ~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER ATTN: BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 .............................................................. >: ~::p~Et1QE3:~Edit~R~b}~Y:~'t'HtS:~E~Ft7'I~1C~4'i~~:~:~>:~:~:~:~:~: ~: POLICYHOLDER JEFFREY BUCCIERO DBA HUDSON VALLEY RENOVATIONS 184 SMITHTOWN RD FISHKILL NY 12524 POLICY NUMBER °A 1324 085-8 DATE 10/03/2011 CERTIFICATE NUMBER 516-169 CERTIFICATE HOLDER TOWN OF WAPPINGER ATTN: BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 10/23/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~ ~~O ~I o T o O .. _ ~y ~, _ ~ N of ~' Zo/i c~FRN~~R k / CANCELLATION U-26.3 THE STATE INSURANCE ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 1219 cTnrnni-~i~nn ~ STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICA'~-~~F NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of sured ~!~ g lb. B siness Telephone Number of Insured ~~~IC Ii~V/ I~ Qnc_~ o_o:cc Envirostar Corp 50 Fields Lane OCT 0 3 2,011 lc. BreFVSter, NY 10509 TOWN OF WAPPING ;~ row Work Location of Insured { n y ~ ~s specifically limited to certain locutions in New York State, i.e., a Wrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) Town of Wappinger 20 Middlebush Road Wappingers Falls, NY 12590 Unemployment Insurance Employer ~tration Number of Insured leral Employer Identification Number of Insured Social Security Number ',275 3a. Name of Insurance Carver Peerless Insurance Company 3b. Policy Number of entity listed in box "la" WC7123648 3c. Policy effective period ' 09/29/11 to 09/29/12 3d. The Proprietor, Partners or Executive Officers are X included. (Only check box if all partners/officers included) ^ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la' for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (1V~ must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carver or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box ` 2". The Instmance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled dtie to nonpa>-ment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate tJte insured from the coverage indicated on this Certif cafe. (These notices may be sent by regular mail) Otherwise, t)tis Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box "3c", whicltever rs earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must pro~zde that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Ja H Dedrick Donald B Dedrick Aaenc Inc. (Print name of a'unthorized/representative or licensed agent of insurance carver) ~~r ~./ 9/28!2011 Approved by: (Date) (Signature) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 84~-877-3333 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-10.3. Insurance brokers are NOT authorized to iss:~e it. ~1vtiv.wcb. state.ny.us C-105.2 (9-07) NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (914j 701-2120 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY125900324 :~:.:.:.RL~2iQE3:.EC~1t~R~Ei:~$Y: ~ 7Wi5:~C~E2TI~iCAt~~: ~:~:~:~: ~:.:.:.:.: POLICYHOLDER WATER WORKS PLUMBING INC P 0 BOX 133 GARRISON NY 105240133 POLICY NUMBER +W 1177 073-2 DATE 9/27/2011 CERTIFICATE NUMBER 570-490 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY125900324 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1177 073-2 UNTIL 4/25/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/25/2012 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 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. / ~~~\ 0~,~/OF ,~Q1pJJ T~~1'N wgnal C~FR/`GFR U-26.3 ~~ ~. THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING ...,.. STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFIC MPENSATION INSURANCE COVERAGE 1a. Legal Name 8 Addr ss o ~Iness0. nlyj VV •~1b. Business Telephone Number ofinsured 83-8 JOVAN & SONS INC 336-6 (845) 266-4478 354 RUSKEY LN SEP 2 ~ 2011 HYDE PARK NY 12538 1c. NYS Unemployment Insurance Employer TOWN OF WAPPINGER Registration Number of Insured Workl:ocation of Insur d On/~~~~l~~e is 1690816 specifically limited to certain ocat~ons m o a e, i.e., ~ P li U W ~ ; ~ 1d. Federal Employer~ldentification Number of , o cy) rap- p a ~ ~ Insured or Social Security Number ~ 14-1.835387- 2. Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Federated Mutual Insurance Company TOWN OF WAPPINGERS FALLS 8 3b. Policy Number of entity listed in box "1 a" 20 MIDDLEBUSH RD TOWN OF WAPPINGERS FALLS NY 12590 9863168 3c. Policy effective period 10/29/2011 to 10/29/2012 3d. The Proprietor, Partners or Executive Officers are: inClUded. (Only check box if all partnerslofficers included) x! all excluded or certainpartners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "1 a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers'-compensation insurance policy). -The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate __ _ _ holder in box "2". The Insurance Carrier will also notify the above certificate holder within 70 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate fhe insured from the coverage indicated on this Certificate. (These, notices maybe sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by-the insurance carrier or its licensed agent, or until the policy expiration date listed in box "3c'; whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Title: Telephone Number of authorized representative or licensed agent of insurance carrier: (888) 333-4949 Please Nofe: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 Ed. 09-07 www.wcb.state.ny.us New York State Insurance Fund• Workers' Cn»>pcirsati~~n B D/sabi//n~ Benefrls Specia/fists Siircc 1914 199 CHURCH STREET;-NEW YORK, N.Y°10007-1100 Phone: (888) 997-3863 CERTIFICATE OF WORKERS' COMPENSATION INS ^^^^^^ 113371600 NATIONAL MAINTENANCE INC D/B/A NATIONAL SIGN AND ELECTRIC 185 SWEET HOLLOW ROAD OLD BETHPAGE NY 11804 POLICYHOLDER NATIONAL MAINTENANCE INC D/B/A NATIONAL SIGN AND ELECTRIC 185 SWEET HOLLOW ROAD OLD BETHPAGE NY 11804 POLICY NUMBER T CERTIFICATE NUMBER Z 1327 758-7 166800 CERTIFICATE HOLDER U ANt~~ ~~//~~jj ~~O ~~~ ~W SEA 2 3 Z~''1 SON pF ~liq ~ ~.. `t~iN CC ppjN '^,~A., FRkGFR .. TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590-0324 PERIOD COVERED BY THIS CERTIFICATE DATE 11 /01 /2007 TO 11 /01 /2012 7/27/2011 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY N0. 1327 758-7 UNTIL 11/01/2012, 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. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 11!01/2012 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 DOES NOT APPLY TO THOSE JOB SITES WHICH ARE COVERED BY OTHER INSURANCE AND ARE SPECIFICALLY EXCLUDED BY ENDORSEMENT. 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 ~q~~ U DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 888739280 U-26.3 389/CD38059-20/1331 NEW YORK STATU~TTE INSURANCE FUND 1 WATERVLIET AVENUE ~518)S4U37~6400ANY, NEW YORK 12206-1649 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE G°~~C~~~d~D TOWN OF WAPPINGER SEP 16 201 BUILDING DEPARTMENT 20 MIDDLEBUSH RD TpWN pF WAPPI K ER WAPPINGERS FALLS NY 12590 -rpwN CLER POLICY NUMBER "A 1381 409-0 DATE 9/12/2011 CERTIFICATE NUMBER 506-949 ~:•;: ~P.C-~21fxEi:~EC31f~R~l~: ~ $Y:~?HIS:~Ir~T:I~:ICA7f~: ~: ~>:~:~: ~:~: ~: ~: :::::::::::~~ f~~~~~r8:::~a::::::~:f:~~f:~~yz :::::::::::::::::::::::::: POLICYHOLDER E-Z FLOW GUTTERS LLC 1059 MAIN ST FISHKILL NY 12524 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1381 409-0 UNTIL 3/16/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 3/16/2012 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 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. THE STATE INSURANCE FUND f' _ ~a Jc. U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 2~5 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE %TE 5ION, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 :~`:;::PL~Eifaf3>E~311~~~Ci::BY:::~WI~::C~i~fi'I~EC~'f~~>:~:~:~>:~:::~:~: POLICYHOLDER TREE LZNE BUILDERS INC 51 MYERS CORNERS RD WAPPINGERS FALLS NY 12590 POLICY NUMBER *A 1298 203-9 DATE 9/07/2011 CERTIFICATE NUMBER 656-966 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1298 203-9 UNTIL 7/11/2012 , COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 7/11/2012 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. '"M'~ ~~.fA `' 1 -~~. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT ~ AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. SEP 1 ~ 2011 TOWN OF WAPPINGER TOWN CLERK THE STATE INSURANCE FUND ~~ U-26'3 DIRECTOR, INSURANCE FUND UNDERWRITING 397 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 POLICYHOLDER ~: ~::.'•::1?C-~2fQE3:: EO'1I~R~CS: ~ SY: ~ TWIS:~E~FtTI~:~CR'Cf;::::::::>::::::::: TREE LINE BUILDERS INC 51 MYERS CORNERS RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1298 203-9 DATE 8/25/2011 CERTIFICATE NUMBER 656-966 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 9/14/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 ~~ g 2011 M ~ ~ AUG 2 ,~~ WN ~F wp,PpINGE TO TOw~ ERK E STATE INSURANCE FUND -~-~ DIRECTOR, INSURANCE FUND. UNDERWRITING ~~, NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (9145 701-2120 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLE BUSH RD WAPPINGER FALLS NY 12590 :~:.:.:.>S~iiQt'~:;CR~~:.$Y:~1~WI~:~E~r~TITi^.:.:~:.:;:~:;:.::: ::::::::::: ~:~~~~~~y~::~~::::::r:f>¢~f~~7z :::::::::::::::::::::::::: POLICYHOLDER AASPEN HVAC INC 3 RUSTED RD APT 13B BREWSTER NY 10509 POLICY NUMBER +W 2091 093-1 DATE 8/29/2011 CERTIFICATE NUMBER 612-067 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLE BUSH RD WAPPINGER FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 2091 093-1 UNTIL 1/08/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORR WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 1/08/2012 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 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. 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. ~y ~!'a ~ \ .~~~ .' 1 ~~ ~~ ~OV ~'o~ SFP o ~Oo TO ~F 1 ~~~i ~N ~~p'°I c~~ "~F THE STATE NCE UND U-26.3 ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 2289 CERT02-2/2001 Technology Insurance Company 5800 Lombardo Center Cleveland OH 44131-2550 CERTIFICATE HOLDER NOTICE NEW YORK WORKERS COMPENSATION INSURANCE COVERAGE' Certificate Holder: Town of Wappingers 20 Middlebush Road Wappingers Falls NY 12590 Insured: Bridge View Excavation Inc. Policy Number: TWC3277701 Policy Period: 4/1/2011 to 9/15/2011 12:01 a.m. at the insured's mailing address Date of Notice: 8/30/2011 Notice Type: Cancellation Effective Date of Cancellation: 9/15/2011 12:01 a.m. at the insured's mailing address Endorsement No.: 1 Reason: Nonpayment As a Certificate Holder on the above policy, you are hereby notified that in accordance with the terms and conditions of this policy, Workers' Compensation Insurance will cease on the date shown for the above named insured. If you have any questions regarding this notice, please contact the insured listed above. By: G ,~~ .-,~ Authorized Representati~@~o~ tl ,• Technology Insurance Company M AmTrust Financial Company A member of the AmTrust Financial Group A.M. Best Rating: A- ~' 1 ~~c~c~o SfP 02 2011 roT~-CLERK ER NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :~::::>P~€ifQF1::EC71l~RECS::$Y:TWI~:~~~Ft?'1l::FGA'T~>:~:~: ~:::::=:~: ~: POLICYHOLDER E-Z FLOW GUTTERS LLC 1059 MAIN ST FISHKILL NY 12524 POLICY NUMBER +A 1381 409-0 DATE 8/30/2011 CERTIFICATE NUMBER 506-949 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 9/19/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~~~~~~ D CANCELLATION U-26.3 SEP 0 2 ?011 TOwN OF .~.Ow wAPPINGER N CLERK THE STATE INSU/~RANCE FUND cam- a~ DIRECTOR, INSURANCE FUND UNDERWRITING hRl Service Center 301 WOODS PARK DRIVE CLINTON NY 13323 (866) 467-8730 Fax: (800) 308-5459 THE ~°'` HARTFORD 09/05/11 N s 0 g s 001426 Town of Wappinger 20 Middlebush Road Wappinger Falls, NY 12590 Insured Name: THE GREAT AMERICAN SIGN COMPANY INC DBA Policy Number: OISBARD8313 Effective Date: 10/06/10 Expiration Date: 10/06/11 To whom it may concern: Our records indicate that a certificate of Insurance was issued, providing proof of insurance, on behalf of the above named insured. This is to inform you that effective 08/23/11 ,all coverage shown on the certificate for the above policy number is cancelled. Should you have any questions, please do not hesitate to contact our office. Sincerely, Your Customer Service Team at The Hartford ~CC~L~OMCD SEP 0 8 Zp» TOWN OF WAPPINGER TOW(V CLERK NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICYHQLDER ::::::::::d~~~~~~~:::~~::::::~:fa~«r~r~ ::::::::::::::::::::::::::: POLICY NUMBER +A 1251 722-3 DATE 8/19/2011 CERTIFICATE NUMBER 424-107 CERTIFICATE HOLDER TIM BECK CONSTRUCTION INC 75 VASSAR RD POUGHKEEPSIE NY 12603 TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 9/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR. INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POL CY. ~~~ ~~~~D D AU~'2 3 2p>> `~ W T ~ N OF ~..:.. - TOWN ~gPPINGER `~ LERK THE STATE INSURANCE FUND CANCELLATION U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 267 sTncaN-~»nn ~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~! TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICYHOLDER ~: ~:::::: i?~tiQES:: E ~3V~RE?CS:. SY:.1~Hi ~:: EL Ei'i'I ~EG;~TL ~: ~: ~: ~>: ~: ~>: ~: ~: ~:::::::::: ~~~~~~I~o~:: ~,~::::::~:f ~~ f~~r ~ ::::::::::::::::::::::::::: TIM BECK CONSTRUCTION INC 75 VASSAR RD POUGHKEEPSIE NY 12603 POLICY NUMBER +A 1251 722-3 DATE 8/19/2011 CERTIFICATE NUMBER 464-833 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 9/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 ~~~ ~~~~D D A~QZ 3 2011 T ~wN ~F .~ ''' ~. TQ WAPpj/~ ~ ~ ~. ~. INN C~ER MFR ~~ K THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 265 STOCAN-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICYHOLDER ~~:~:.:.:,p~E#1CxEl:.6C31t~R~fS:~~Y:~'1'FII$:~>r:1~:IC~ti'I~~:~:~:~:~:~<:~: ~`: TIM BECK CONSTRUCTION INC 75 VASSAR RD POUGHKEEPSIE NY 12603 CERTIFICATE HOLDER POLICY NUMBER +A 1251 722-3 DATE 8/19/2011 CERTIFICATE NUMBER 123-404 TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 9/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. / ~~~~ AUp' r~wNn~ 23?oJ1 CANCELLATION U-26.3 151 ~ \~~VN WgpplN C GE ~~ LFRK R THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (914f 701-2120 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~ `~ "`, .~ '~ ~: ~~~ TOWN OF WAPPINGER 20 MIDDLE BUSH RD WAPPINGER FALLS NY 12590 POLICYHOLDER ~~~~~~ D r AUG~ 2 5 2011 TOWN OF WAPPINGER TOWN .CLERK ::':;RCRfQD CO~tERED:~$Y`TW15`CAE}TIF:{GA7ir:~:~:~:~:~:~:~:~::: s ~o8r;~~w :r~~:::::~:f:f:~a~ar~ ::::::::::::::: AASPEN HVAC INC 3 HUSTED RD APT 13B BREWSTER NY 10509 POLICY NUMBER +W 2091 093-1 DATE 8/22/2011 CERTIFICATE NUMBER 612-067 CERTIFICATE .HOLDER TOWN OF WAPPINGER 20 MIDDLE BUSH RD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 9/11/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. THE STATE INSURANCE FUND CANCELLATION U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 3323 STATE OF NEW YORK WORKERS' 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 1 a. Legal Name and Address of Insured (Use street address only) 1 b. Business Telephone Number of Insured MONARCH CONSULTING INC (818) 729 - 0080 DBA PES PAYROLL lc. NYS Unemployment Insurance Employer Registration (NEW YORK EMPLOYEES) Number of Insured 4100 W BURBANK BLVD BURBANK, CA 91505 1 d. Federal Employer Identification Number of Insured or Social Security Number 770464154 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) NATIONAL BENEFIT LIFE INSURANCE COMPANY MONARCH CONSULTING INC. DBA 3b. Policy Number of entity listed in box "la": PES PAYROLL, PAEINC 4100 WEST BURBANK BLVD. 8-910-0210012 BURBANK„ CA 91505 3c. Policy effective period: 06/13/2011 to 06/13/2013 4. Policy covers: a. 0 All of the employer's employees eligible under the New York Disability Benefits Law b. ^ Only the following class or classes of the employer's employees: Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above cribed above. a de s and that the named insured has NYS Disability Benefits insurance coverage /s ~ . ~ _ ~ Date Signed 06/13/2011 By ~t~~_ (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 800-535-2711 Title Vice President 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 purposes of Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed for completion to the Workers' Compensation Board, DB Plans Acceptance Unit, 20 Park Street, Albany, New York 12207. PART 2. To be completed by NYS Workers' Compensation Board (Only if box "4b" of Part 1 has been checked) State Of New York Workers' Compensation Board According to information maintained by the NYS Workers' 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 Workers' Compensation Board Employee) Telephone Number Title Please Note: Only insurance carriers licensed to write NYS disability benefits insurance po ~gents icies~~~~ of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers ar !tc~ NO a s orm. DB-lzo.l (s-ob> AUG 1, $ 2011 TOWN OF WAPPINGER TOWN CLERK New York State Insurance Fund Workers' Compensation & Disability Benefits Specialists Since 1914 1 WATERVLIET AVENUE ALBANY, NEW YORK 12206-1649 Phone: (518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^ ^ " ^ ^ ^ 141829054 MID HUDSON CONSTRUCTION MANAGEMENT INC 210 NEW HACKENSACK RD WAPPINGERS FALLS NY 12590 POLICYHOLDER CERTIFICATE HOLDER MID HUDSON CONSTRUCTION MANAGEMENT INC 210 NEW HACKENSACK RD TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 WAPPINGERS FALLS NY 12590 POLICY NUMBER A 1290 038-7 CERTIFICATE NUMBER 668429 PERIOD COVERED BY THIS CERTIFICATE 01 /25/2011 TO 01 /25/2012 DATE 8/16/2011 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1290 038-7 UNTIL 01/25/2012, COVERING THE ENTIRE .OBLIGATION OF THIS POLICYH_ OLDER 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 01/25/2012 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 POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. NICHOLAS J DELUCCIA PRES OF MID HUDSON CONSTRUCTION MANAGEMENT INC (1 PERSON CORP) 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. ~ ~~ ~~~ .~`~ ,'.^ r D Arc 1 ~ z0» T~~N~Fw ro wN ~ PpI N~FR NEW YORK RANC FUND ~q~~ U DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 550122271 U-26.3 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name 8 Address of Insured (Use street address only) 1b. Business Telephone Number of Insured JOVAN & SONS INC 336-683-8 (845) 266-4478 354 RUSKEY LN HYDE PARK NY 12538 1c. NYS Unemployment Insurance Employer Registration Number of Insured 1690816 Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, i.e., 1d. Federal Employer Identification Number of a Wrap-Up Policy) Insured or Social Security Number 14-1835387 2. Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Federated Mutual Insurance Company TOWN OF WAPPINGERS FALLS 8 3b. Policy Number of entity listed in box "1 a" 20 MIDDLEBUSH RD TOWN OF WAPPINGERS FALLS Y 1~~ 9863168 ~1~~~'L~D . Policy effective period ~~ 07/28/2011 to 10/29/2011 AUG 1 5 2011 . The Proprietor, Partners or Executive Officers are: TOWN OF WAPPINGE ®included. (Only check box if all partners/officers included) TOWN CLERK ~ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "1 a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also notify the above certifrcate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums fhat cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices maybe sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box "3c'; whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that/the named ints~ure(d' h`as the` coverage as depicted on this form. ~ ~ ~~~--~, t' RYJt Y~O n rn~ ~TTi .~l `' ~ ~ ~ Approved by: "~°•-~~ Approved by: name of authorized representative or licensed agent of insurance carrier) (Signature) ~ (Date) Title: Caw Telephone Number of authorized representative or licensed agent of insurance carrier: (888) 333-4949 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 Ed. 09-07 www.wcb.state.ny.us CANCELLATION/TERMINATION NOTICE Third PartYCopy CERTHOLDER Insured: JOVAN & SONS FUEL OIL INC 354 RUSKEY LANE HYDE PARK, NY 12538 Cancellation/Termination of each policy listed below was requested by the insured. Page 1 of 1 Place of Issue: FEDER~lITED INSURANCEv 121 East Park Square PO Box 328 Owatonna, MN 55060 According to contract language in the policies listed below, we will continue to protect your interest as a mortgagee, additional insured, or a loss payee through the date and time of day shown below. Policy Time of Policy CancellationlTermination Policy Number Policy Type Date Cancellation/Termination" 9294641 Commercial Package Policy 07/28/2011 12:01 a.m. 9294642 Umbrella 07/28/2011 12:01 a.m. 9294644 Worker's Compensation 07/28/2011 12:01 a.m. "Standard time at the designated business premises. ~. ~~C~L~Ot~L~D AUG 12 Zp>> TOWN OF WAPPINGER TOWN CLERK TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH RD TOWN OF WAPPINGERS FALLS NY 12590 Loss Payee/ Mortgagee/ Additional Insured/ Certificate Holder Account No. 225-892-9 Date: 08/05/2011 FEDERATED MUTUAL INSURANCE COMPANY. FEDERATED LIFE INSURANCE COMPANY. FEDERATED SERVICE INSURANCE COMPANY. AA C(1_A(1 //17_!101 4J(1AAC (1CCIf C• (1\A/NTIIAI AIA AAI AI AICC(1T /\ CCnCl1 1 GOO 'I'17 AnAn Erie° Insurance Group 100 Erie Ins. PI. Erie, PA 16530 MAIL DATE AGENT'S NAME AGT N0. POLICY N0. 08/04/2011 A C PEPE INSURAN NN1422 Q33 7220103 OTHER INTEREST ANCHOR ELECTRIC INC TOWN OF WAPINGER 38 FOX RD 20 MIDDLEBUSH RD HOPEWELL JUNCTION NY WAPPINGERS FALLS N 12533-5024 Y 12590-4004 IN CONSIDERATION OF THE ABOVE PAYMENT WE TAKE THE FOLLOWING ACTION: WE HEREBY RESCIND THE CANCELLATION NOTICE EFFECTIVE AUGUST 09, 2011 PERTAINING TO THIS POLICY. THE CANCELLATION NOTICE MAY BE DISREGARDED AND YOUR POLICY PROTECTION WILL CONTINUE IN FULL FORCE. 00712 THIS NOTICE SHALL BE EFFECTIVE ONLY IF YOUR PAYMENT IS HONORED BY YOUR FINANCIAL INSTITUTION (~LC~C~~d[~D AUG 1 0 2~ 11 TOWN OF WgppINGER - TOWN CLERK 9061E (R) 6/97 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE F.,,XTE~iSION, ALBANY, NEW YORK 12206-1649 1518)) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :~:~::p~E21QE5:~E~.'~(~R~C~:~$Y:~?WIS>~~R7'I~:FGA'Ff~:~:~:~:~:~:~:~:~:~: POLICYHOLDER HERRING SANITATION SERVICE INC 1072 RTE 9 ~~1 FISHKILL NY 125242547 POLICY NUMBER +A 1267 807-4 DATE 7/14/2011 CERTIFICATE NUMBER 893-493 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/03/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~ ~,. CANCELLATION U-26.3 / ~ ~ ~\ r, ` ~ ~0 ~. ~~'~ ~~~ a. ~ ~., THE STATE INSURA CE F 1; ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING ~n~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, :NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS BUILDING DE 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ::::.: ~::i>~€tiQd::cC3~i~Et~>$v:.:~Hi~:. ~~€t1~~F~c~t~~: ~::>?::::>:::.: POLICYHOLDER HERRING SANITATION SERVICE INC 1072 RTE 9 ~~1 FISHKILL NY 125242547 POLICY NUMBER +A 1267 807-4 DATE 7/14/2011 CERTIFICATE NUMBER 072-315 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DE 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/03/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ,. "U \ (/ G CANCELLATION U-26.3 ~~ ~~ Q ~~ ~~..~° F ~` ~ ,1 THE STATE INSURA C FUND ~Q~ DIRECTOR, INSURANCE FUND UNDERWRITING 7~S NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SION, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS BUSH RD WAPPINGER FALLS NY 12590 POLICYHOLDER ~:~>:~:~PC-~1Qb:~EC31f~R~d: $Y::?WI>~::lr~Et?I~:EGA7f~:~:~:~:~::::::::`: HERRING SANITATION SERVICE INC 1072 RTE 9 ~~1 FISHKILL NY 125242547 POLICY NUMBER +A 1267 807-4 DATE 7/14/2011 CERTIFICATE NUMBER 362-328 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUSH RD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/03/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY •OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 ~. 7) `~. ~~, %i ~ `~ ~u~ G `~ f ,, `'~ ~ ,~:~~. ~~ •,„~~ THE STATE INSA F DIRECTOR, INSURANCE FUND UNDERWRITING 335 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS MIDDLEBUSH RD WAPPINGER FALLS NY 12590 :~:~:~RC,€t1QE9:~E0:5l~REb: ~SY:~?WIS::~~€~TI~FCAtf~:~:~:~:~5:~:~:~:~: ~:~:~:~:~:~tZ~:3n~1 ~~f~fi~: ~Ff~:~:~:~~~f>a~J~~QX ~:~:~:~:~:~:~:~:~:~:~:~:~: POLICYHOLDER HERRING SANITATION SERVICE INC 1072 RTE 9 ~~1 FISHKILL NY 125242547 POLICY NUMBER +A 1267 807-4 DATE 7/14/2011 CERTIFICATE NUMBER 368-122 CERTIFICATE HOLDER TOWN OF WAPPINGERS MIDDLEBUSH RD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/03/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFIC¢~TE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. CANCELLATION U-26.3 , ~ , ; ^~' tA~P i ~ \ ~~ ~ ~ ~~ , J) ~y>~¢ z ~' I.'.. THE STATE INSUI DIRECTOR, INSURANCE FUND UNDERWRITING ~~~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE $ION, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ~: ~:.::~1?C~€2ifaE3:. EOV~R~I~.'•$Y:~i=Wig:~~~€tTIF:FG;iTi'~:~:~:~:~:~:~:~:~: ~: POLICYHOLDER HERRING SANITATION SERVICE INC 1072 RTE 9 ~~1 FISHKILL NY 125242547 CERTIFICATE HOLDER POLICY NUMBER +A 1267 807-4 DATE 7/14/2011 CERTIFICATE NUMBER 379-091 TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/03/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOE T AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ,a ~.. ~~ ~., \,. (~ ;/,rte ,` ~`: , CANCELLATION U-26.3 a ~ ~">~ ~w °y ~ O~j ~ t~!~~ P P ~; - ~ ,,..~ fq~ ~...~` ~w '`V~~ _ ~ ,~~, ~, THE STATE INSURA FUND DIRECTOR, INSURANCE FUND UNDERWRITING Rio STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Natne and address of Insured (Use street address only) ]b. Business Telephone Number of Insured Thomas Gleason, Inc. 845-454-3730 lc. NYS Unemployment Insurance Employer 42 McKinley Lane Registration Number of Insured 1713062 Poughkeepsie NY 12601 ld. Federal Employer Identification Number of Insured Additional Named Insureds: or Social Security Number Northside Supplies, LLC 141438793 Work Location of insured (Only req:ilred if coverage is specifically limited to certain locations in New York State, i.e. a Wrap-Up Policy) 3. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Technology Insurance Company Town of Wappinger 3b. Policy Number of entity listed in box "la": 20 Middlebush Road TWC3277899 3c. Policy effective period: Wa In ers Falls NY 12580 PP~ 9 4/1/2011 to 4/1/2012 3d. The Proprietor, Partners or Executive Officers are: included. (may check box if all partners/oRicers included) all excluded or certain partners/officers excluded. 'fltis certifies that the insurance carrier indicated above in box "3" insures the business referenced above in boa "]a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York t'NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notify the above certificate holder within 1 D d~vs IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on t{ris Certificate. (7'Irese notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box " 3c ", whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, 1 certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Henry C. Sibley (Print name of authorized representative or licensed agent of insurance cattier) Approved by: ~ •,,, (Date) Telephone Number of authorized representative or licensed agent of insurance carrier 607-724-0173 ', 2-_ 1 `1 '~ ~. Please Note: Only insurance carriers and Their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized Jo issue it. C-105.2 (9-07) 7n1zo11 (Signature) Title: Underwriting Manager [~ - ~ ~ l_ JUL 1 5 20 ~ i NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~" TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGER FALLS NY 12590 ~_ ._ __ y~ , POLICY NUMBER +A 1309 095-6 DATE 7/11/2011 CERTIFICATE NUMBER 031-795 ............................................................... . :~:;:~::pCEt]QE1:~E~3St~R~15::$V:~1'WtE:~C~E~1'1~:FCA'CP~:::;`:~::::: ~:::;: 'L' POLICYHOLDER KEVIN MCMORRIS DBA GENESIS HOME CONTRACTING 48 SMITH CROSSING RD WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 7/31/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. y_,_.,~ JUL ~ 4 2011 ~,c~a~~~~s~~R S) F ~ .N CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 563 c-rnr~ni_~ inn ~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE F~XTENSION, ALBANY, NEW YORK 12206-1649 t518 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGER FALLS NY 12590 f ~ ,' _: a. POLICY NUMBER +A 1309 095-6 DATE 7/11/2011 CERTIFICATE NUMBER 102-174 >:::~:~A~?i«FS:~C~.rt~R~b:: ~~`:i'HiS:~E~Ft~'I~iGi4't~;::::`::>::`::::: POLICYHOLDER KEVIN MCMORRIS DBA GENESIS HOME CONTRACTING 48 SMITH CROSSING RD WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 7/31/2011. THIS INFORMATION IS FiJRNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE .AND ANY OTHER CERTIFICATE OF' INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~~~~~:~ JUL ~ 4 ZO'1 CANCELLATION U-26.3 773 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING cTnrnni_a ionn ~ NEW YORK STATE INSURANCE FUND 199 CHURCH STRiE8$8N997Y086~ N.Y. 10007-1100 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY125900324 :~:~:~~~€2iOb:~EOrf~R~d:~8Y:~1~Wi5'ir~€~TI~iGa*~~`:~:~:~':~>':~: POLICYHOLDER NATIONAL MAINTENANCE INC D/B/A NATIONAL SIGN AND ELECTRIC 185 SWEET HOLLOW ROAD OLD BETHPAGE NY 11804 POLICY NUMBER ~~Z 1327 758-7 DATE 7/07/2011 CERTIFICATE NUMBER 166-800 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY125900324 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1327 758-7 UNTIL 11/01/2011 , COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 11/01/2011 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 REGISTERED MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO THOSE JOB SITES WHICH ARE COVERED BY OTHER INSURANCE AND ARE SPECIFICALLY EXCLUDED BY ENDORSEMENT. 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. r..`_ U-26.3 " ~ Lam; , /- r~ I~ ~ _. mil; ~~~ f~ ` ~-~ i L ~~~ ~ 2 2D 11 ~ ~~ ~-~-. ,~ Tp l/lf~l~,! ' qtr THE STATE INSU1tA1~E~-P-I.I~ ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 491 /`C ~T/l l _ O /O!1!~ . NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (914f 701-2120 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY POLICYHOLDER 12590 POLICY NUMBER +W 1351 411-2 DATE 6/24/2011 CERTIFICATE NUMBER 560-214 ~:~:::1?~€21bE3: EC3'1t~I~~D:~SY::tW15::lr~E#:~IF:{G;4Ff ::::::'::::::: :~::::::~d:~.~~~~:1t::~4::::: 7 f:~;4f.~~7:t ::::::::::::::::::::::: CERTIFICATE HOLDER ALAN PARSHLEY CONTRACTING LTD 176 TIBET DRIVE CARMEL NY 10512 TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 7/14/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. G 4•,~' ~'.., #. 7 ~'.• 1 CANCELLATION U-26.3 J// ~`~r;< N 2 8 ,r, F P A"Df a~ ".. 3~ ~t~ THE STATE INSUrRANCE FUND d DIRECTOR, INSURANCE FUND UNDERWRITING 2151 STDCAN-2/~nn1 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICYHOLDER ~;::: ~: ~ R C~€#iQE3: ~ E O.ilGRED: ~ $Y: ~ tHIS: ~ EEf{tIF:~C;4Ti^:: ~: ~ `:::;:::::: ~: HERRING SANITATION SERVICE INC 1072 RTE 9 ~~1 FISHKILL NY 125242547 POLICY NUMBER +A 1267 807-4 DATE 6/14/2011 CERTIFICATE NUMBER 379-091 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 7/04/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. fr -, ~ ~~,- i_) JUN 17 `~;? CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING 707 STDCAN-2/2170 1 STATE OF NEW YORK WORKERS' COIvTPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name and address of Insured (Use street address only) lb. Business Telephone Number of Insured SK ELECTRIC, LLC 271 Route 9D 845-742-7059 Beacon, NY 12508 lc. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically N/A limied to certain locations in New York State, i.e. a Wrap-Up ld. Federal Employer Identification Number of Insured Policv) Or Social Security Number 51-0503445 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) AmGUARD Insurance Company Town Of Wappinger 3b. Policy Number of Entity listed in box "la": Attn: Michelle Gale 20 Middlebush Road SKWC244963 Wappingers Falls, NY 12590 3c. Policy effective period: 07/18/2011 to 07/18/2012 3d. The Proprietor, Partners or Executive Officers are: ^ included. (Only check box if all parmerslofficers included) ® all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box " 3" insures the business referenced above in box "Ia" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation ins ~ licensed agent will send this Certificate of Insurance to the entity listed above as the ce ficate~~~~'~ n~D The Insurance Carrier will also notify the above certificate holder within 10 days IF a olicy is canceled due to nonpayment of premi ms or within 30 days IF there are reasons other than nonpayment of premiums that cancel e policy or eliminate the insured from the c erage indicated on this Certificate. (`T'hese notices may he sent by regular mail.) Otherwise, his CertificatA~~i«lld~rximum of o~ year after this form is approved by the insurance currier or its licensed agent, or until the licy expiration date listed in box "3c'; whic ver is earlier. TOWN OF WAPPINGER Please Note: Upon the cancellation of the workers' compensation policy indicat don this r~>~~ b s ~ie~s~i>~nues to named on a permit, license or contract issued by a certificate holder, the busines ew Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, 1 certify that 1 am an authorized representative or licensed agzut of the insurance carrier r~fvr~nced above and that the named insured has the coverage as depicted on this form. Approved by: Marshall Kornblatt (Print name of authorized representative or licensed agent of insurance carrier) Approved by: (Signature) Title: Executive VP of Insurance Operations (Date) Telephone Number of authorized representative or licensed agent of insurance carrier: 800-673-2465 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue il. 08/05/2011 C-105.2 (9-07) www.wcb.stat.ny.us NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (914f 701-2120 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 TOWN OF WAPPINGERS 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 ::.: A~€tiba: E~.il~R~b>8Y: tHi5: ~~t~T1~:1G;47E';::: ::: :::::::::5 ~ 0~l ~~~5 :~1~:~::~5f o8:1~(~~2:::::::::::: POLICYHOLDER EDWARD SPADARO CONSTRUCTION INC 264 SEMINARY RD CARMEL NY 10512 POLICY NUMBER +W 1354 064-6 DATE 8/01/2011 CERTIFICATE NUMBER 380-543 CERTIFICATE HOLDER THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1354 064-6 UNTIL 5/08/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 5/08/2012 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 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 NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. TuT~ AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY TIiE~OLICY._ U-26.3 9023 AND CONFERS GHTS .s++-~-~TSFI' A~DOE NOT ~~`' i~'7 C~C~~ ~ ~, AUG 0 5 c~S1 TOWN Or ~ ~.j ~,PPINGER TOWN CLERK THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 ~:~>':~i?~#i~E3:. CC31i~i~~Ci?81!`mHi~>Cif#i'I1':~CA'f~~:`•:.>:~:.:.`:: ~: POLICYHOLDER ROBERT WILSON MANAGEMENT LLC 28 CROFT RD POUGHKEEPSIE NY 12603 CERTIFICATE HOLDER POLICY NUMBER +A 1438 205-5 DATE 8/02/2011 CERTIFICATE NUMBER 167-650 TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/22/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. Ull'~C~I.~[1~~,~D AUG 0 5 2~ i1 TOWN OF ~~VAPPINGER TOWN CLERK CANCELLATION U-26.3 939 THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGER FALLS NY 12590 :~:;:~:~i?~€#1Qd::E~31f~~~D::f3Y:~'T.WIC:~ir~F2:TI~:~C;47~~:~:~:~:~:~:~:~:~: POLICYHOLDER KEVIN MCMORRIS DBA GENESIS HOME CONTRACTING 48 SMITH CROSSING RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1309 095-6 DATE 7/25/2011 CERTIFICATE NUMBER 102-174 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGER FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1309 095-6 UNTIL 10/25/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 10/25/2011 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. 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. I~ I " J~ ,-~-~ JUL 2 s 25~'~ ~~ I~~ THE STATE INSURANCE FUND U-26.3 .`~~- DIRECTOR, INSURANCE FUND UNDERWRITING h01 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~iSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGER FALLS NY 12590 POLICYHOLDER ~:?:: ~:~i?~~2ff1E3::6(35l~~~t~:~$Y:~ 1'WI~>~~f{?I~:FGA7~~:~:~:~: ~:~::::: KEVIN MCMORRIS DBA GENESIS HOME CONTRACTING 48 SMITH CROSSING RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1309 095-6 DATE 7/25/2011 CERTIFICATE NUMBER 031-795 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGER FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1309 095-6 UNTIL 10/25/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 10/25/2011 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 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. ~~4jm~~`"`~" °• ----•-•--._ ~~-- i ~ ~\ ~~f-' 11-,,1' ?~-_- -~ i L. i ~ , JUL 2 8 2011 ,, K ° r`:k~ '. f THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING fi (17 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SION, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~'~ TOWN OF WAPPINGERS BUSH RD WAPPINGER FALLS NY 12590 :~:~f?~€if1Q.d::yE-.C/311~R~b:~f3~1!y::1'W?Iii;::C~j~./€fiTIf=:FyCA'f~~:~:~:~:~':<~:~: POLICYHOLDER HERRING SANITATION 1072 RTE 9 ~~1 FISHKILL SERVICE INC NY 125242547 POLICY NUMBER +A 1267 807-4 DATE 7/22/2011 CERTIFICATE NUMBER 362-328 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUSH RD WAPPINGER FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1267 807-4 UNTIL 12/30/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 12/30/2011 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 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. ~`~ ,..,,.~. r JUL 2 S 2Gfi1 ~~ A '' THE STATE INSURANCE FUND U-26.3 =._v _ T DIRECTOR, INSURANCE FUND UNDERWRITING 775 r~~nrn~-~ inn ~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518? 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~~ TOWN OF WAPPINGER 20MIDDLEBUSH RD 24 Downey Ave. WAPPINGERS FALLS NY 12590 POLICYHOLDER :~:.:.:.i?iota:.E~.~R~d:~~Y:~tWi~:~~~i~~IK~Cat~~:~:~:.>:.:_:.: BRYAN MURPHY CONSTRUCTION INC 24 DOWNEY AVE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1482 281-1 DATE 7/22/2011 CERTIFICATE NUMBER 668-149 CERTIFICATE HOLDER TOWN OF WAPPINGER 20MIDDLEBUSH RD 24 Downey Ave. WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/11/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 JUL 2 8 2011 ~. ~° THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 5R7 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~iSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~~ TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICYHOLDER ~:.:.:. i?~2iQFS:. COrI~RE=Ci: ~ f3Y: ~ 1~WI~: ~ ~~t~tIF:EC,a~f.: ~> :.:.:.:.:.:::.: BRYAN MURPHY CONSTRUCTION INC 24 DOWNEY AVE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1482 281-1 DATE 7/22/2011 CERTIFICATE NUMBER 714-812 CERTIFICATE HOLDER TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/11/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 w. JUL 2 8 2~ i _" Tta , t ~m~ ~'t~ 6~ ~ ~~ THE STATE INSURANCE FUND ~~-~ DIRECTOR, INSURANCE FUND UNDERWRITING 5R1 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~~ TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICYHOLDER ~: ~:.:.pf=Rit~iE~:; cov~i~Eb: ~$~:; tHis>e~i3t~~:~car~ ::::::.:.:::.:.:.: BRYAN MURPHY CONSTRUCTION INC 24 DOWNEY AVE WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER POLICY NUMBER +A 1482 281-1 DATE 7/22/2011 CERTIFICATE NUMBER 668-155 TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/11/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. C~~~r ~~ l: ~ 1 ~~ CANCELLATION U-26.3 JUL 2 8 2C i1 THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING 577 NEW YORK TE INSURANCE 105 CORPORATE PARK DR, ST 2 ITE PLAINS, c 91~~~ ~;fir-21.20 CERTIFICATE OF R;K'401VIPE1~1~, . TIOr ~(I~ 2 6 2~' ~ r°~~~ b ~~ TOWN OF WAPPINGER FALLS ~' , .,, `~- '~~r: ' ',~~~ 20 MIDDLEBUSH ROAD ~ ~~r~~ ~~ ~ ~'~~FR WAPPINGER FALLS NY 12590 ~~`"• ~~~ __:- :::>::::P~€iii?E3:,EC~V~R~Ci:: f3Y:. THi~:.~~€trIF:EGa~~:::::::::: ~: ~: ~:~: ~: POLICYHOLDER JOHN FALVELLA INC 47 UNION SCHOOL RD MONTGOMERY NY 12549 POLICY NUMBER *W 1369 249-6 DATE 7/21/2011 CERTIFICATE NUMBER 900-821 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER FALLS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1369 249-6 UNTIL 10/03/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 10/03/2011 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 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. THE STATE INSURANCE FUND ~~ U-26'3 DIRECTOR, INSURANCE FUND UNDERWRITING FUND NEW YORK 10604-3814 69 rFRTn~-~i~nn~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ~: ~::: ~: ~ 1?C~€i1f}~:: E011~t?~d: ~ $Y::1W1}s::1r~€tTIF:ECAC~~: ~»'::::::::: POLICYHOLDER HERRING SANITATION SERVICE INC 1072 RTE 9 ~~1 FISHKILL NY 125242547 POLICY NUMBER +A 1267 807-4 DATE 7/22/2011 CERTIFICATE NUMBER 379-091 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1267 807-4 UNTIL 12/30/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 12/30/2011 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 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. r~~~- ~- ,, _ ..__~ ~~~ ~~~ ~ - I I~ ~~- ~ -, -~. ~ ee JUL 2 ~ ZJi3 .._ .. .,. _.~ .. __u ~V.., ,, r~ THE STATE INSURANCE FUND ~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 741 r~oTn~_~ionn~ NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR,~SmF. inn wrrTTF., AT.,~~ NEW YORK 10604-3814 CANCELLATION OF JUL 2 2 2011 ~~ TOWN OF WAPPINGER FALLS I 20 MIDDLEBUSH ROAD L WAPPINGER FALLS NY 12590 TOW~J ~~i~ ~~~~`~,~~TiiI~ER ~-~v~v~v ~~.~~~ 1 :~:::~:~R~#istE:~EC3.ri~t~l?::SY::1~WI~:: CLE~1'I~iCA'I~~::: ~::::::::::'::: POLICYHOLDER JOHN FALVELLA INC 47 UNION SCHOOL RD MONTGOMERY NY 12549 POLICY NUMBER +W 1369 249-6 DATE 7/19/2011 CERTIFICATE NUMBER 900-821 CERTIFICATE HOLDER TION INSURANCE TOWN OF WAPPINGER FALLS 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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, EXTEIv'B OR ALTER THE COVERAGE AFFORDED BY THE POLICY. CANCELLATION U-26.3 THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 911 STDCAN- 2/2001 NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (914f 701-2120 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +w 1354 064-6 DATE 7/22/2011 CERTIFICATE NUMBER 380-543 :~>RC-~€t1QE3:~EC3Sl~R~t~:~BY:~fiHlrs:~~~t~~`I~:{C;47~~:~:~:~:~>:~: ~:~: POLICYHOLDER EDWARD SPADARO CONSTRUCTION INC 264 SEMINARY RD CARMEL NY 10512 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/11/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFE 0 RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFI TE`tBi~'S NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~„ , r JUL 2 7 2011 T®W~f ~ ~_ ~~i'.~~7~IfV~~R TQ~~~~ ~:? ~R~ CANCELLATION U-2b.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING t RR'2 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~iSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS BUILDING DE 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~:~PC,€21fZE3:~6~11~R~b:~$1!:~tFIIS:~C~f{tI~:IGQ~f~:~:~>:~:~:~:~:~:~: POLICYHOLDER HERRING SANITATION 1072 RTE 9 ~~1 FISHKILL SERVICE INC NY 125242547 POLICY NUMBER +A 1267 807-4 DATE 7/22/2011 CERTIFICATE NUMBER 072-315 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DE 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1267 807-4 UNTIL 12/30/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 YORR STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 12/30/2011 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 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. ~~ ~~~ ~ ') JUL 2 ~ 20i1 R~, TO~I,rG.,, ; ~~~? ~~ E ~ 'e .~. _ _. : i THE STATE INSURANCE FUND ~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING ~7Q nr..+ .... .. ........ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE ~XTE~VSION, ALBANY, NEW YORK 12206-1649 1518)) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 %::~A~€2iQa`EOrl~t~~CS: ~f3Y:~1~Hi5:~~~€~tI6:IC;47~~::~:~:~:~:~:~:~:~: ::::::::::::~z~:~n~~>xt~~:::~~:::~~t~~~:~¢r~ ::::::::::::::::::::::::::: POLICYHOLDER HERRING SANITATION 1072 RTE 9 ~~1 FISHKILL SERVICE INC NY 125242547 POLICY NUMBER +A 1267 807-4 DATE 7/22/2011 CERTIFICATE NUMBER 893-493 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1267 807-4 UNTIL 12/30/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 12/30/2011 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 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. _ ~~~`'~' _ JUL 2 7 2011 _ i THE STATE INSURANCE FUND ~a~-~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 71A r~orn~_~i~nn~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS MIDDLEBUSH RD WAPPINGER FALLS NY 12590 POLICY NUMBER +A 1267 807-4 DATE 7/22/2011 CERTIFICATE NUMBER 368-122 ................................................................ :~:~:~A.E€i1QE3:~E01t~R~d:~8Y:~7WIS:~C~€t?IK:4GATf~:~»::{~:<~:~: ::::::::::rz~:~n~~~~~::::~~:::~~:t~~~~r~ ::::::::::::::::::::::::::: POLICYHOLDER HERRING SANITATION 1072 RTE 9 ~~1 FISHKILL SERVICE INC NY 125242547 CERTIFICATE HOLDER TOWN OF WAPPINGERS MIDDLEBUSH RD WAPPINGER FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1267 807-4 UNTIL 12/30/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 12/30/2011 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 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 NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~ AND CONFERS NO RIGHTS CERTIFICATE DOES NOT ~,1~~ ~ -~i~, ;i_- JUL 2 '~ 2G1 T~~i~ ~,: ;~ ~~ e ~. ,, .. THE STATE INSURANCE FUND ~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 777 rcnrnn nin nn. NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (914 701-2120 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :>:.:;>PC~€2i~7iE3:.E01t~F~ti:. f3Y ~wig:.~~€~7'I~:EGv.~tf::.:.::5:.:.:.>: :::::::::z~:s~~~a~:::~~::::::~:t:~~:~:~~y~ :::::::::::::::::::::::::: POLICYHOLDER EXPLICIT EXTERIORS INC 262 TOAD PASTURE ROAD MIDDLETOWN NY 10940 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +W 2066 202-9 DATE 7/26/2011 CERTIFICATE NUMBER 159-909 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/15/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE 1~'C _I.___..._ ~.__ __._.__..___ _._,..~_ JUL 2 9 2C11 CANCELLATION U-26.3 ONLY AND CONFERS NO RIGHTS THIS CERTIFICATE DOES NOT ~O`yifi'~ ~~_~~~C THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING ~~R~ NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~: ~:.:.PC-~2iOb:~Cb1[~R~Ci:.$Y`7Wi~:~C~r{~Ii=:GCaT~::.:.>:.>:.:.: ~: POLICYHOLDER NAC INDUSTRIES INC 160 AIRPORT DRIVE WAPPINGERS FALLS NY12590 POLICY NUMBER +Z 2093 204-2 DATE 7/26/2011 CERTIFICATE NUMBER 121-558 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/15/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. l1~ " ~~~ %! ~' i ~' CANCELLATION U-26.3 ,~~ '~ `' ~` '•- Q'J '`'~ r " ~" ~ , i ~,~ ~. ~~ ~~ ~. ~ ~ ter, t~'-y f ~i h ~~t THE STATEINSURANC FUN DIRECTOR, INSURANCE FUND UNDERWRITING ;zu{ NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLE BUSH ROAD WAPPINGER FALLS NY 12590 POLICY NUMBER +G 2046 911-0 DATE 7/26/2011 CERTIFICATE NUMBER 612-085 :>:~P~21Qd:~6(711~1~~D:~B~!:~tWl~:~lr~t~~'I~:EGAt~~:~:~:~:~:~:~:~>: POLICYHOLDER FOLKES HEATING, COOLING & BURNER SERVICE INC 850 ROUTE 9 FISHKILL NY 12524 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLE BUSH ROAD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/15/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. n `'' ~~ ~,:, ~-~, ~' ~_ ~.. ._ . ~ .. - ~ :, t^~~ ~(/ '~ '_ r~~cs/~r ,. ~ ~ ~ z~,, CANCELLATION U-26.3 f P.. ~> THE STATE INSURANCE ~~ DIRECTOR, INSURANCE FUND UNDERWRITING ~fi'~9 NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8~8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~: >:~PC~€21QE1:~E0'1t~R~D:~f3Y:~?WIS:~~~€~TIK:IGA'~f~:~:~:~:~:~:~:~:~:~: POLICYHOLDER FOLKES HEATING, COOLING & BURNER SERVICE INC 850 ROUTE 9 FISHKILL NY 12524 POLICY NUMBER +G 2046 911-0 DATE 7/26/2011 CERTIFICATE NUMBER 698-990 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 8/15/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~ CANCELLATION U-26.3 rQ ~_ ~~ z 9 J ~R ~ ~~ , ~ ~ 2Q1~ ~f ~ h ~ \ ~ <~ ~ J ,; ~ / THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 5(71 • STATE OF NEW YORK "C WORKERS' COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1. To be completed by Disability Benefits Carrier or LicensbeBunness Telephone NumbeaofCInsulred la. Legal Name and Address of Insured (Use street address only) g45-849-5084 SELECT CONTRACTING LLC lc. NYS Unemployment Insurance Employer ATTN: JIM Registration Number of Insured 44 GILMORE BLVD WAPPINGERSFALLS,NY12590 ~~~~'~~~ d , ld. Federal Employer Identification Number of JAN 2 6 2010 Insured or Social Security Number 263335741 3a. Name of Insurance c;arrter 2. Name and Address of the Entity Requesting r f 'age Zurich American Insurance Company (Entity Being Listed as the Certificate Holder) gg South Service Road, Melville, NY 11747 Town of Wappingers Building Department 3b. Policy Number of entity listed in box "la": 20 Middlebush Road 5476697 - 001 Wappingers Falls, NY 12590 ~,,,._~ ~ ~ ~~l ~ ~ ~ 3c. Policy effective period: ~--~'' ~ ~ 9/28/2009 To 9/28/2010 4. Polic covers: a. ~ All of the employer's employees eligible under the New York Disability Bene Its aw b. ~ Only the following class or classes of the employer's employees: Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability Benefits insurance coverage as described above. 1/25/2010 ~'''~'k'R'~ Date Signed BY (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Title Operations Manager Telephone Number (631)845-2200 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, thYhe Workers'rCompensaOtion Boa df DB Plpans Acceptance Unrt, 20 Park Street AlbanyTyNew York 12207, must be mailed for completion to C if State Of New York Workers' Compensation Board According to information maintained by the NYS Workers' 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 Workers' Compensation Board Employee) Telephone Number Title Please Note: Only insurance carriers licensed to wForm DB-120.1! Insurance brokers are1NOT authorized to issdue this form. ents of those insurance carriers are authorized to issue -DB-120.1-{5-06) _ - - - - ___ - _ - _ Additional Instructions for Form DB-120.1 By signing this form, the insurance carrier identified in box " 3" on this form is certifying that it is insuring the business referenced in box "la" for disability benefits under the New York State Disability Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box " 2". This Certificate is valid for the earlier ojone year after this form is approved by the insurance carrier or its licensed agent, or the policy expiration date listed in box "3c". Please Note: Upon the cancellation of the disability benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of NYS Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law. DISABILITY BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article, and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. DB-120.1 (5-06) STATE OF NEW YORK WORKERS' 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 la. Legal Name and Address of Insured (Use street address only) lb. Business Telephone Number of Insured MID HUDSON CONSTRUCTION MANAGEMENT, INC 8452989230 210 NEW HACKENSACK ROAD lc. NYS Unemployment Insurance Employer Registration Number of Insured WAPPINGERS FALLS, NY 12590 4571172 Id. Federal Employer Identification Number of Insured or Social Security Number 14-1829054 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Wappinger 3b. Policy Number of entity listed in box "1 a": Building Department 20 Middlebush Rd D79745-000 Wappingers Falls, NY 12590 3c. Policy effective period: 1 /24/2001 to 8/14/2012 4. Policy covers: ' a. r All of the employer's employees eligible under the New York Disability Benefits L ~~{~ '~"`" Y u ~~ b, (- Only the following class or classes of the employer's employees: o ~~~~f 1) A(l~ ~ ~ 2011 TpwN ~F ;_ oBC~tfd~~t~~c Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insura a carrierTe~~E!lt ' •' Y named insured has NYS Disability Benefits insurance coverage as described above. `J CL C~~ L C Date Signed 8/16/2011 gy Signature of insuran carrier's a horized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212) 355141 Title SUPERVISOR-DBL/POLICY SERVICES 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 purposes of Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed for completion to the Workers' Compensation Board, DB-Plans Acceptance Unit, 20 Park Street, Albany, New York 12207. PART 2. To be completed by NYS Workers' Compensation Board (Only if box "4b" of Part 1 has been checked) State Of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation Board, the above-named employer h c ted t the NY i Disability Benefits Law with respect to all of his/her employees. Date Signed By (Signature of NYS Workers' Compensation Board Employee) Telephone Number Title Please Nofe: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (5-06) NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 ~518J 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ~>:.:: • Rt=€214.E):: E011~R~I?:: SY:;?Wig: ~ Ctft1~ IF:EGA7P~>.'•::: ~>: ~::: ~>: ::::::::::::tz~:~.~~~~~~:::~:~:::~~:f;~~~~r~ ::::::::::::::::::::::::::: POLICYHOLDER HERRING SANITATION 1072 RTE 9 ~~1 FISHKILL SERVICE INC NY 125242547 POLICY NUMBER +A 1267 807-4 DATE 6/17/2011 CERTIFICATE NUMBER 379-091 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1267 807-4 UNTIL 12/30/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 12/30/2011 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 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. - JUN 2 2 2011 ti..J ~`.~ t V t.s 5.~:.~ Y `~...__.V.._~ THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 1R1 ~corn~_~i~nn~ i STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) lb. Business Telephone Number of Insured JP1207 LLC 914-769-5132 24 Usonia Road lc. NYS Unemployment Insurance Employer Pleasantville, NY 10570 Registration Number of Insured Work Location of Insured (Only required [fcoverage is specifically ld. Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e., a Wrap-Up or Social Security Number Policy) 203315042 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) The Hartford Town of Wappingers 3b. Policy Number of entity listed in box ~°la" 20 Middlebush Road 16WECZW2618 Wappingers Falls, NY 12590 3c. Policy effective period 06/1/2011 to 06/1/2012 3d. The Proprietor, Partners or Executive Officers are Included. (Only check box if all partners/officers included) Q/ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy).. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notify the above certificate holder within 10 days IFa policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy exp[ration date [fisted in box "3c", whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying wyth the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the above and that the named insured has the coverage as depicted on this form. Approved by: John C. Webb, Jr. (Print name of authorized represent~ve or licensed agent ~- i~ (Date) Approved by: Title ~~ ~ °!/ ca r erenced /~~ %~ _ ~' ~~. ~~~ `~; `\ ~, O f, ~J ~~ ~ ~~~ fi ~~ President, Emery & Webb Telephone Number of authorized representative or licensed agent of insurance carrier: 845-855-1112 ~~~~C Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Ins anc broke 4zre ~~ authorized to issue it. C-105.2 (9-07) ww : ,cb.state.ny.us q STATE OF NEW YORK WORKERS' 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 la. Legal Name and Address of Insured (Use street address only) lb. Business Telephone Number of Insured 914-769-5132 JP 1207 LLC 1145 ROUTE 9 lc. NYS Unemployment Insurance Employer WAPPINGERS FALLS, NY 12590 Registration Number of Insured ld. Federal Employer Identification Number of Insured or Social Security Number 203315042 2. Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Zurich American Insurance Company Town of Wappingers 58 South Service Road, Melville, NY 11747 20 Middlebush Road Wappingers Falls, NY 12590 3b. Policy Number of entity-listed in box "la": 6477095 - 001 3c. Policy effective period: 6/1/2011 To 6/1/2012 4. Polic covers: a. ~X All of the employer's employees eligible under the New York Disability Benefits Law b. ~ Only the following class or classes of the employer's employees: Under penalty of perj ury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability Benefits insurance coverage as described above. ~t~.~..i'~~-~ 61t4/zott g y Date Signed (signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (631) 845-2200 Title Operations Manager 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 purposes of Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed for completion to the Workers' Compensation Board, DB Plans Acceptance Unit, 20 Park Street, Albany, New York 12207. PART 2. To be com leted b NYS Workers' Com ensation Board Onl if box "4b" of Part 1 has been checked State Of New York Workers' Compensation Board According to information maintained by the NYS Workers' 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 Workers' Compensation Board Employee) Telephone Number Title Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorised to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (5-06) Rochdale Insurance Company 5800 Lombardo Center Cleveland OH 44131-2550 CERTIFICATE HOLDER NOTICE NEW YORK WORKERS COMPENSATION INSURANCE COVERAGE Certificate Holder: Town of Wappingers 20 Middlebush Rd Wappingers Falls NY 12590 Insured: O'Shea Electrical Contractors, Inc. Policy Number: RWC3221097 Policy Period: 11/1/2010 to 11/1/2011 12:01 a.m. at the insured's mailing address Date of Notice: 5/27/2011 Notice Type: Reinstatement Endorsement No.: 2 Reason: As a Certificate Holder on the above policy, you are hereby notified that the NOTICE OF CANCELLATION effective 6/9/2011 is superceded. Coverage has been reinstated without lapse for the policy period noted above. If you have any questions regarding this notice, please contact the insured. By: ~ ~ ~~ ,• Rochdale Insurance Company AmemberoftheAmTrustFinancialGroup An AmTrust Fnancial Company A. M. Best Rating: A- Authorized Representative O ~~ c~/s, n TO /UN '~ ~~ j o Oo ''(/OV ~~ ° °~~~ ~~"~~~~ ~ 105 CORPORATENPARK DORKTS 200 E~NSE RANK E NE N~ RK 10604-3814 (914f 701-2120 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~- TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY125900324 POLICYHOLDER >:;:::;1?~€i1<).E3:~CC351!?~[~ffY:~?WIS:~E~€+:7'I~EC;47f :~ ::::::::::::: WATER WORKS PLUMBING INC P 0 BOX 133 GARRISON NY 105240133 POLICY NUMBER +w 1177 073-2 DATE 6/08/2011 CERTIFICATE NUMBER 570-490 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY125900324 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 6/28/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 ~::..: ` " (~~~~~ /~ ~~ T®~~~~, N102p~, ~:` , ~~? ~~ THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING ~04~ '~ STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVF,RA[:i•, la. Legal Name & Address of Insured (Use street address only) lb. Business Telephone Number of Insured 845-452-3520 Mannino Electric, Inc. lc. NYS Unemployment Insurance Employer 4 Buckingham Ave. Registration Number of Insured Poughkeepsie, NY 12601 Work Location of Insured (Only required if coverage is specifically ld. Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e., a Wrap-Up or Social Security Number Policy) 14-1670465 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Selective Insurance Co. Town of Wappingers Building Department 3b. Policy .Number of entity listed in box "la" 20 Middlebush Road W C7939064 3c. Policy effective period Wappingers Falls, NY 12590-0324 06/05/11 to 06/05/12 3d. The Proprietor, Partners or Executive Officers are included. (Only check box if all partners/d'ficers included) X all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "1a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notes the above certificate holder within 10 days IF apolicy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate tis valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box "3c", whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other.authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or.lic~nsed agent of a insp~°ance carne ~enc~,d above and that the named insured has the coverage as depicted on this form. _ (,, , ~ 17~~D Approved by: Michael H. Spam { ~' ~ (~ (Print name of authorized representative or licensed agent of insurance ca ier) ~ViV ) n O„ ~ ~~~ Approved by: June 6, 2011 ~~ 1`' g-~' (Signature) (Date) Title: President of Spain Agency Telephone Number of authorized representative or licensed agent of insurance carrier: (845) 628-4500 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-07) www.wcb.state.ny.us Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employmentdefined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-07) Reverse NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER ATTN: BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY POLICYHOLDER TIMBER CREEK HOMES 87 DIDDELL ROAD WAPPINGERS FALLS 12590 >::::::P~1CtE3'E~V~R~b:~BY: ~ mHI~:~C~FtI'IK:EG~4'~~: ~: ~:~:~:~: ~:=:~: ~: POLICY NUMBER +A 1212 777-5 DATE 6/01/2011 CERTIFICATE NUMBER 703-153 CERTIFICATE HOLDER INC NY 125906227 TOWN OF WAPPINGER ATTN: BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1212 777-5 UNTIL 8/05/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORR WORK- ERS' 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 8/05/2011 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 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 THErPAbiCY. ~~~ r;_,n~, n~' .`: ~J °~ ~, . JUN p 6 ~~,.1 ~ ` ! ~ ~ ~r~p ~~< C THE STATE INSURANCE FUND U-26.3 " DIRECTOR, INSURANCE FUND UNDERWRITING 385 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY POLICYHOLDER TIMBER CREEK HOMES 87 DIDDELL ROAD WAPPINGERS FALLS 12590 POLICY NUMBER +A 1212 777-5 DATE 6/01/2011 CERTIFICATE NUMBER 649-224 :~:;::::1?~E#1CtE3::C~lSI~R~b::>~Y`'I'WII~:; E~Ft1'IF:EG~4'f~<~: ~:~:~: ~:~: ~:~: ~: CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 INC NY 125906227 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1212 777-5 UNTIL 8/05/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 8/05/2011 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 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. ~~' t ~~ ~:,,~ J~., ~ 6 2011 ~~ ~ ,,~ ~r ~ . ~. ~~ ~ ~ ~. ~p~NGER __ ._ =RK THE STATE INSURANCE F- iJ1~II' d- U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 383 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICYHOLDER TIMBER CREEK HOMES 87 DIDDELL ROAD WAPPINGERS FALLS :~:.:.:.i~~iicxE3:.E~V~R!~t~:.8~:.1~Wi~:;E~t~fi1F:-C~~:~:~`:~:~.'•: ~`: ~: :::::::::::~:~o~~~~lo-~::::~~::::::~:fa~f~~r~ :::::::::::::::::::::::: POLICY NUMBER +A 1212 777-5 DATE 6/01/2011 CERTIFICATE NUMBER 921-331 CERTIFICATE HOLDER Irrc NY 125906227 TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER -NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1212 777-5 UNTIL 8/05/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 YORR STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 8/05/2011 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 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 NGR INSURANCE COVERAGE UPUN THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. U-26.3 +C. 1 ~~N V v/ ~~ ~, . T~, ~,; : ~. ; 2011 ,, ' ~-aPpl,~~~f~ ; °E~K THE STATE INSURA !ND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 257 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-838-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 :~::::::P~ifQf3`E~31l~F~b::f3~::1'Wilts'~~f~I'I~:EC~k'I~;>:~:~:~:~:~:~: ~: ::::::::::: s ~ z.~ l~~ag:::~~:::::: ~:f z~ f~a~ r ~ ::::::::::::::::::::: POLICYHOLDER ROCK-ALL CONSTRUCTION INC 1365 RUSTIC RIDGE CT. YORKTOWN HEIGHTS NY 10598 POLICY NUMBER *G 1087 080-6 DATE 6/01/2011 CERTIFICATE NUMBER 938-950 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 6/29/2011. THIS INFORMATION IS FURNISHED YOU IN COPiPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY -OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 'S - . _.....~.~. ~ ~Ny.. !'._~ .. , ~~ ~~` JUN p 6 2011 -': ~~ ~-11VGER T THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 3707 STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SION, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER FALLS 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 :~::'`f?L~t1f~Eti:;E~1l~R~b::BY:;'1'W15:;~~E~:I~:EC~'I~::;::::: ~>:~:~:~:~: ::::::::::;~~o~~~~a~::::~~::::::~:f,a.5 f~~r ~ :::::::::::::::::::::: POLICYHOLDER TIMBER CREEK HOMES INC 87 DIDDELL ROAD WAPPINGERS FALLS NY 125906227 POLICY NUMBER +A 1212 777-5 DATE 6/01/2011 CERTIFICATE NUMBER 921-142 CERTIFICATE HOLDER TOWN OF' WAPPINGER FALLS 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1212 777-5 UNTIL 8/05/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER 'THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 8/05/2011 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 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. 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. _~_! ~_ ~~,~ ~~ ~~>~=,~~ JUN 0 6 20'1 TOV~~~ ~ ~:~ '=.~F r, ~~~GER ~ ~ ~ ~P-_ ~ THE STATE INSURANCE FUND U-26.3 =~ .._.a DIRECTOR, INSURANCE FUND UNDERWRITING 391 CERT02- 2/2001 NEW YORK STATE INSURANCE 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, (914f 701-2120 CERTIFICATE OF WORKERS' COMPENSATION ~~ TOWN OF WAPPINGERS 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 :~:.:.:.P~€2i~E3:~E0~RED:~B~:~tWl~'C~€~7~I~:EC~7~ :~:~:~:~:~:=':~>: POLICYHOLDER EDWARD SPADARO CONSTRUCTION 264 SEMINARY RD CARMEL Ny INC 10512 POLICY NUMBER +W 1354 064-6 DATE 6/03/2011 CERTIFICATE NUMBER 380-543 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1354 064-6 UNTIL 5/08/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 5/08/2012 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 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. -. ~~~~_-_,,,,,~,D ~~ JUN ~ ~ ® ? IGr1 `~. TV 6 ~ ~';t THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING FUND NEW YORK 10604-3814 INSURANCE ~z~o NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE F~XTENSION1 ~~ , EW YORK 12206-1649 CANCELLATION OF CERTI ICA C~~'I~M p .~ ~ ~~~ - JUN032011 ~~ TOWN OF WAPPINGER 'rpUVI~ ~S~ ~~~s~-~i~Ii~~ER BUILDING DEPARTMENT ""~"~;~ 1~.~.~~.K 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 TION INSURANCE POLICY NUMBER +A 1381 409-0 DATE 5/31/2011 CERTIFICATE NUMBER 506-949 :~::::::12~1Qd::EC7St~RLC5f3Y:~TWti:~lr~Et~`IK:IGAT~~:~:~:~::~: ;~::: POLICYHOLDER E-Z FLOW GUTTERS LLC 26 HILLCREST CT WAPPINGER FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 6/20/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 1205 STDCAN-2/2001 Rochdale Insurance Company 5800 Lombardo Center Cleveland OH 44131-2550 CERTIFICATE HOLDER NOTICE NEW YORK WORKERS COMPENSATION INSURANCE COVERAGE Certificate Holder: Town of Wappingers ~\,~ 20 Middlebush Rd ~~ `a,`'~` ~ Wappingers Falls NY 12590 l/ j~D UN Tp ~, 0 3 2( ;1 ~ ~„'`~ Insured: ~ OShea Electrical Contractors, Inc. ~ ~ ~i "" ~~~r'~: Policy Number: Policy Period: RWC3221097 r , ;(t f! "`~,~?' ~'~-`"~='~-~__ 11/1/2010 to 6/9/2011 12:01 a.m. at the insured's mai _ _ ling address ~~' / Date of Notice: 5/26/2011 9~ r, ~ ~ ~° ~~ Notice Type: Cancellation Effective Date of Cancellation: Endorsement No : 6/9/2011 12:01 a.m. at the insured's maili ng address , 4 Reason: Prem Due 195.00 As a Certificate Holder on the above policy, you are hereby notified that in accordance with the terms and conditions of this policy, Workers' Compensation Insurance will cease on the date shown for the above named insured. If you have any questions regarding this notice, please contact the insured listed above. By. __ ~ ~~ Authorized Representative ,• Rochdale Insu ce Company An AmTrust Fnancial Company A member of the Am Trust Financial Group A.M. Best Rating: A- NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE~90~j ?HIT212pAINS, NEW YORK 10604-3814 CANCELLATION OF CERTIFICATE OF O l~1~PENSATION INSURANCE ~ . _~ , -~ k ~~ TOWN OF WAPPINGERS 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 G°~L~~[~01~[~D MAY 26 2~~1 TOUV~ Oi~= ~~~r~i~T~GER ~`~i/~I~ ~L~RK ~: ~:::::: p L~i1niF3:: C ~.5t~ R~~: ~ f3Y::'I'W I ~:: ir<€t1'I F:FC~4~~:: ~: ~: ~: ~::: <~: ~: ~: POLICYHOLDER EDWARD SPADARO CONSTRUCTION INC 264 SEMINARY RD CARMEL NY 10512 POLICY NUMBER +W 1354 064-6 DATE 5/23/2011 CERTIFICATE NUMBER 380-543 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 6/12/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 12533 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~- ~:~~~"~ BUOILD NGIDEPARTMENT ~~ ~,~,;tu' i~-~ 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 MAY 2 6 ZGi1 TOWR9 C~~° 4JV~~r='F~If~GER T®WI~ CLERK •:•:::•:•RC~€tif~f3::E~3. •• • .• •.:: Y:::T.WI~::sr~€~TIFJC~~;:~:::::~:::~:~:~:~: POLICYHOLDER PETER WINDHEIM DBA COUNTRY CONSTRUCTION 220 OLD KETCHAMTOWN RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1263 042-2 DATE 5/23/2011 CERTIFICATE NUMBER 550-211 CERTIFICATE HOLDER T/0 WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 6/12/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 9n~ NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICYHOLDER :~::::::i?C~€21Qt~`6C11l~R~b:~~3Y'?HIS::C~€tTI~:~GA7'~ :::::::::::::::::::: LISIKATOS CONSTRUCTION INC P.O. BOX 309 COLD SPRING NY 10516 POLICY NUMBER +G 1416 145-9 DATE 5/27/2011 CERTIFICATE NUMBER 304-122 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 6/16/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~, !„l, ~' `~ `"" ... ~~ ~~ CANCELLATION U-26.3 ~~` ~,` ~ ~ ~ ~~ ...~ ~, ~~~FR .~ ~ ~.,~. ~_ THE STATE INSURANCE FUND i U~ DIRECTOR, INSURANCE FUND UNDERWRITING ~~~ ~~°-^ 3273 crnrnni_~i~nn~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ T/0 WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY POLICYHOLDER 12590 ~:.>:~i?~EtiQE~>ECG.~R~d:~BY:~tWl~:~~~t~:'fI~:FGi~Tf~ :::.:.:.:.:.:.:.: ~:::::::=toy:o~~~~:>~:~~::aofob:s~c~rt ::::::::::::::::::::: PETER WINDHEIM DBA COUNTRY CONSTRUCTION 220 OLD KETCHAMTOWN RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1263 042-2 DATE 5/27/2011 CERTIFICATE NUMBER 550-211 CERTIFICATE HOLDER T/O WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1263 042-2 UNTIL 10/01/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 10/01/2011 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 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 ONL CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. TH S C DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIC ~ ( !~ ~/N(~, ~~ -_- n~~L~© ,., r~ TC r JUN 0 2 2011 ~~ ~ ~ t +pW~~J~~~~~ ~-_ ~ ~ THE STATE INSURJ/~ANCE FUND l~C j \ - ' - U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 1033 CERT02-2/2001 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1. To be completed by Disability Benefits Carrier or Li censed Insurance Agent of that Carrier la. Legal Name and Address of Insured (Use street address only) lb. Business Telephone Number of Insured DUTCHESS BUILDING SPECIALISTS, INC. 845-485-8343 FREEDOM EXECUTIVE PARK -STE 130 lc. NYS Unemployment Insurance Employer 488 FREEDOM PLAINS ROAD Registration Number of Insured POUGHKEEPSIE, NY 12603 3921418 ld. Federal Employer Identification Number of Insured or Social Security Number DBA :DUTCHESS DECKING 141735231 2. Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Zurich American Insurance Company Town of Wappingers 58 South Service Road, Melville, NY 11747 20 Middlebush Road Wappingers Falls, NY 12590 3b. Policy Number of entity listed in box "la": 1992961 - 002 3c. Policy effective period: 3/22/2011 To 3/22/2012 4. Polic covers: a. ~X All of the employer's employees eligible under the New York Disability Benefits Law b. ~ Only the following class or classes of the employer's employees: Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability Benefits insurance coverage as described above. d st27t2o~~ ~~,4 ,~ / D t Si gy , , a e gne (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (631). 845-2200 _ Title Operations Manager 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 purposes of Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed for completion to the Workers' Compensation Board, DB Plans Acceptance Unit, 20 Park Street, Albany, New York 12207. PART 2. To be com leted b NYS Workers' Com ensation Board Onl if box "4b" of Part 1 has been checked State Of New York Workers' Compensation Board ; G! , ~ r ~ l; , According to information maintained by the NYS Workers' Compensation Board, the above-named a ployer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. MAY 31 2t~ i Date Signed gy (Signature of NYS Workers' Compensation Boazd Employee) t ) A' ~ °~ ~. ~ Telephone Number Title c ~. ~ ~ 4 ~ ~ ~ ~, ~ 1 r 2; ~ Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorised to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (5-06) Additional Instructions for Form DB-120.1 By signing this form, the insurance carrier identified in box "3" on this form is certifying that it is insuring the business referenced in box "la" for disability benefits under the New York State Disability Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box " 2". This Certiftcate is valid for the earlier of one year after this form is approved by the insurance carrier or its licensed agent, or the policy expiration date listed in box " 3c ". Please Note: Upon the cancellation of the disability benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of NYS Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law. DISABILITY BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article, and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. DB-120.1 (5-06) NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518 ) 4`37-6',4,00 CANCELLATION OF CERTIFICATE OF ~V~ERS' COMPENSATION INSURANCE ~~'~' ~a TOWN OF WAPPINGER T~ M'4Y2 4 ~~ 20 MIDDLEBUSH ROAD A~~/ ~~`, ~~// WAPPINGERS FALLS NY 12 0 f o ~~~, ~ '.~~~~kGFR ~ ...................................:..............:............. :~:<~RC-~€t1Qf3:~E0'1f~REd:~BY>?WIB>ECG?'IKiC./~7P~:~:~:~:~:~:~:~:~:~: ::::::::::;~;'~i~~~~rr.~:::~~::::::~:f,oaf:~ar~ ::::::::::::::::::::::::::: POLICYHOLDER TIMBER CREEK HOMES INC 87 DIDDELL ROAD WAPPINGERS FALLS NY 125906227 POLICY NUMBER +A 1212 777-5 DATE 5/19/2011 CERTIFICATE NUMBER 921-331 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 6/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-2b.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 357 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKER' COMPENSATION INSURANCE U11 ~~~~]n/J~~ ~~ TOWN OF WAPPINGER j BUILDING DEPARTMENT MAY 2 4 Z`^~ 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12 9~i0~~f ~~ t~E,',4~~r~GER ~" ~~t~~ ~~.EF~K ~: ~"RC~€2iQE3:~EC3~RE~: ~f3Y: ~?Fli~::~~€tTl~iGi~~t~~: ~: ~: ~:~:~:~: ~: ~: ~: ::::::::::~~:o~~~~rr.~:::~c~::::::~:f~~~:~ar~ :::::::::::.::::::::::::::: POLICYHOLDER TIMBER CREEK HOMES INC 87 DIDDELL ROAD WAPPINGERS FALLS NY 125906227 POLICY NUMBER +A 1212 777-5 DATE 5/19/2011 CERTIFICATE NUMBER 649-224 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 6/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 749 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER FALLS 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 ``, n~ ~ ~ ,~ ~:~:~:~P~€i1Qd:~EC3Sll POLICYHOLDER TIMBER CREEK HOMES INC 87 DIDDELL ROAD ,WAPPINGERS FALLS NY 125906227 °C~C~(~~M~~n MAY 2 4 TOWS ~:~r. 'JV~,~~~i`~~ER TO~~ CLERK POLICY NUMBER +A 1212 777-5 DATE 5/19/2011 CERTIFICATE NUMBER 921-142 CERTIFICATE HOLDER TOWN OF WAPPINGER FALLS 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 6/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING X49 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SION,_ALBANy NFL YORK 12206-1649 ~-..,~ .. CANCELLATION OF CERTIFICATE ~~~~ ~'~ ~ ~PEN~ATION INSURANCE ~~ TOWN OF WAPPINGER ATTN: BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~" ti... ~:•x•P.ER1Qd:~CO'1tEREC~:~BY:~?HIS:~>rEFITIE:EGI>'~f~:~:~:~:~:~:~:~:=:~: POLICYHOLDER TIMBER CREEK HOMES INC 87 DIDDELL ROAD WAPPINGERS FALLS NY 125906227 POLICY NUMBER +A 1212 777-5 DATE 5/19/2011 CERTIFICATE NUMBER 703-153 CERTIFICATE HOLDER TOWN OF WAPPINGER ATTN: BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 6/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 MAY 2 4 ~ ~'.1 TOWN G= ~+V f:,~~I(~GER TAW N CLERK THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 251 _ J t A t l~. Ut^ Nl~; W Y UK1C ~` WORKERS' COMPENSATION BOARD --`~' CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) lb. Business Telephone Number of Insured 845-628-3610 Dutchess Environmental 936 Route 6 lc. NYS Unemployment Insurance Employer Mahopac, NY 10541 Registration Number of Insured 32-91758 ld. Federal Employer Identification Number of Insured Work Location of Insured (Only required if coverage is or Social Security Number specifically limited to certain locations in New York State, i.e., a 16-1533676 Wrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Ilolder) Peerless Insurance Company ~ . Policy Number of entity listed in box "la" "' WC8445359 Town of Wappinger 20 Middlebush Rd ~ ~~` " licy effective period Wappinger Falls NY 12590 u `~ !~ (~ ~ ~! %~ a' a - 05 20/11 to 05/20/12 MAY 2 3 Z~' ~ ~~ ii~f~ 3d. a Proprietor, Partners or Executive Officers are X ncluded O l h k b if ll / ,a~ E . ( n y c ec ox a partners officers v{/ ~ '~ all excluded or certain a t / ffi l d d ~ ~~~ v p r ners o cers exc u e . This certifies that the insurance carrier indicated above in box " 3" insures the business referenced above in box "1 a" for workers' compensation under the New York State Workers' Compensation Law. (To use this farm, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premizms that cancel the policy or eliminate the insztred fi~am the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until flee policy expiration date listed in box "3c", whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Jay H Dedrick Donald B Dedrick A ency Inc. (Print name of authorized representative or licensed agent of insurance carrier) A roved b ~~~ '" 5/19/11 PP Y (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 845-877-3333 Please Note: Only insurance carriers and their licensed agents are azthorized to issue Form C-105.2. Insurance brokers are NOT authori->ed to issue it. C-] 05.2 (9-07) www.wcb.state.ny.us _+ f` Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the .part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or mumicipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly, subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. O ~~ ,~,; C' , , `~'<, , TQ~ ti1gy2 ` ~`'~/ ~r~~~a., ~ if~,_t, ~ , ~~~ ~~ / Technology Insurance Company 5800 Lombardo Center Cleveland OH 44131-2550 CERTIFICATE HOLDER NOTICE NEW YORK WORKERS COMPENSATION INSURANCE COVERAGE Certificate Holder: 't~. ~ .. ;' ~! u U ~`'`--~...~-1 Town of Wappinger ~ 20 Middlebush Road `~ I~ Wappinger Falls, NY 12590 MAY 2 D 20'l TOW _ T®~ ^~/' ~'4ApPI~j Insured: Commercial Contracting Company, Inc. vl/~ ~~~~~ FR Policy Number: TWC3267826 Policy Period: 12/31/2010 to 12/31/2011 12:01 a.m. at the insured's mailing address Date of Notice: 5/12/2011 Notice Type: Reinstatement Endorsement No.: 3 Reason: As a Certificate Holder on the above policy, you are hereby notified that the NOTICE OF CANCELLATION effective 5/11/2011 is superceded. Coverage has been reinstated without lapse for the policy period noted above. If you have any questions regarding this notice, please contact the insured. By' ~ C ~~ ,• Technology Insurance Company An AmTrust Financial Company A member of the AmTiust Financial Group A. M. Best Rating: A- Authorized Representative PART 1. To be Benefits Carrier or Licensed Insurance 1 a. Legal Name and Address of Insured lure sa(ree(addreae only) Swanson Consulting Inc. P.O Box 395 Salisbury Mills NY 12577 of that Carrier 1b. Business Telephone Number of Insured 845-401-4859 ic. NYS Unemployment Insurance Employer Registration Number of Insured 1 d. Federal Employer Identification Number of Insured or Social Security Number 134164776 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the certificate Holder) Town of Wappingers 20 Middlebush Rd Wappingers Falls NY 12590 3a. Name of Insurance Carrier The Guardian Life Insurance Company of America 3b. Policy Number of entity listed in box "1 a": 00967071-0000 3c. Policy effective period: 12/11 /2006 to 12/10/2011 4. Policy Covers: a. ®All of the employer's employees eligible under the New York Disability Benefits Law b. ^ Only the following class or classes of the employer's employees: ~ Under penalty of perjury, I certify that I am an authorized representative or licensed agent ofahe insurance carrier referer~ed above and that the named insured has NYS Disability Benefits insurance coverage as described above. Date Signed: 5/5/2011 By: ~ ~ ~'hAW' Telephone Number: 1-888-278-4542 Stuart J. Shaw, FSA, MAAA Title: Vice President, Group Insurance 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. Mall It directly to the certfflcate holder. If box "4b" is checked, this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the Oisabllity Benefits Law. It must be mailed for completion to the Workers' Compensation Board, DB Plana Acceptance Unlt, 20 Park Street, Albany, New York 12207. PART 2. To be completed by NYS Workers' Compensation Board (Only if box "4b" of Part 1 has been checkec State Of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation 6 rd, .v~-nam complied with the NYS Disability Benefits Law with respect to all of his/her a es. Date Signed: ~' By: Telephone Number: Title: (Signelure of NYS Workers' Compensation Boerd Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies insurance agents of those insurance carriers are authorized to issue Form DB-i20.1, insurance authorized tv issue this form. DB-120.1 (5/06) STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW em f.f-11 IL~'~:J ~ ~~~ MAY 1 812011 T01,~IN ~~ 1N ,NPINGER LERK are NOT Additional Instructions for Form DB-120.1 By signing this form, the insurance carrier identified in box "3" on this form is certifying that it is insuring the business referenced in box "1 a" for disability benefits under the New York State Disability Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box "2". This Certificate is valid for the earlier of one year after this form is approved by the insurance carrier or its licensed agent, or the policy expiration date listed in box "3c': Please Note: Upon the cancellation of the disability benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of NYS Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law. DISABILITY BENEFITS LAW §220.Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article, and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. ~~~ DB-120.1 (5/06) Reverse NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE ~518~54~7~6400ANY, NEW YORK 12206-1649 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 Cat . POLICY NUMBER +A 1315 132-9 DATE 5/09/2011 CERTIFICATE NUMBER 275-024 ~:?<~iSL~tit~E3:~G~31t~~~b: ~ BY:~'1'WIS:~E~~.1'I~:{C.~ti'(~~:~:~: ~:~: ~:~:~:~: ~: ::::::::::z~z~~~a~~:::~:~::::::~:t;~~:~~rz :::::::::::::::::::::::::: POLICYHOLDER SHANE ALEXANDER DBA ALEXANDER CONSTRUCTION 316 MYERS CORNERS RD WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1315 132-9 UNTIL 2/21/2012 , COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 2/21/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CEI~ AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. MAY122~1 TOWN O~ Vun~F~1N~ER T®W~ ~~.ERK THE STATE INSURANCE FUND ~ lq ~v U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 1255 CERT02-2/2001 NEW YORK- STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SION, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 ~" ~ r .~ , POLICY NUMBER +A 1315 132-9 DATE 5/09/2011 CERTIFICATE NUMBER 519-322 ~: ~: ~: ~ P ~E31«E3: ~ E OSt~ ft~D: ~ f3~Y: ~'i'H I B> C~Et7'IF:ICA'I~ ~: ~ : ~: ~: ~»: ~ >: POLICYHOLDER SHAI~TE ALEXANDER DBA ALEXANDER CONSTRUCTION 316 MYERS CORNERS RD WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1315 132-9 UNTIL 2/21/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 2/2i/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY AND CONFERS NO RIGHTS p --.., G, r~ ~~(~, .-J - MAY 1 2 2G~1 TOVV~ ~:.~,N ~~,f:':~~~~~11~ER TO~I~~ ~~E~~ THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 555 CERT02-2/2001 NEW YORK STAT~IE INSURANCE FUND 1 WATERVLIET AVENUE ~518)54~7~6400ANY, NEW YORK 12206-1649 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE G°~CC~~~~~~~D -~ TOWN OF WAPPINGER MAY 1 ~ 2G i 1 .~' 20 MIDDLEBUSH RD ~'' ~~ WAPPINGERS FALLS NY 125 oTC T~ G~~ `v~~~,~~}~~~;ER UW~ ~;LERK ~»: ~p~E#iQD:~CC3Sl~t~~IS:~HY:~I~WIB:~E'I~EC~a'4~~>:~:~:~:~:~:~>:~: ::::::::::~~z~~~~y~:::~~::::::~:tz~f;~ar~ ::::::::::::::::::::::::::: POLICYHOLDER SHANE ALEXANDER DBA ALEXANDER CONSTRUCTION 316 MYERS CORNERS RD WAPPINGERS FALLS NY 12590 ,'POLICY NUMBER +p 1315 132-9 ~ DATE 5/05/2011 CERTIFICATE NUMBER 275-024 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 5/25/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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 AFFORDEB BY THE POLICY. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 259 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 <~: ~:~P.~2ic1Ei:~EC3.rt~R~ti:~BY:~fiWIS<C~~ITi^~:~:~:~:~:~:~: ~:~: ~: POLICYHOLDER SHANE ALEXANDER DBA ALEXANDER CONSTRUCTION 316 MYERS CORNERS RD WAPPINGERS FALLS NY 12590 ~. POLICY NUMBER +A 1315 132-9 DATE 5/05/2011 CERTIFICATE NUMBER 519-322 CERTIFICATE HOLDER TOWN OF WAPPINGER MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 5/25/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~ ~~ ~~ ~ ~ ~J MAY 1 ~ 2011 Tp T~ ~,t,%~,' ~^ LAGER __ _L~/.~KTHE CANCELLATION U-26.3 257 'ATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING crnr n~~_n innn ~ NOTICE OF CANCELLATION, NONRENEWAL, CONDITIONED RENEWAL OR CHANGE IN TERMS, CONDITIONS OR RATES (New York) NAME AND . Century Surety Company ADDRESS 465 Cleveland Avenue OF INSURANCE Westerville OH 43082 COMPANY Castino Corporation DBA Leisure Tech NAME AND . 1300 Route 9 G ADDRESS Hyde Park NY 12538 OF INSURED KIND OF POLICY: General Liability Policy POLICY/APPLICATION/BINDER NO.: CCP698873 EFFECTIVE DATE OF NOTICE: 05/23/11 12:01 (DATE) (HOUR-STANDARD TIME AT THE ADDRESS OF THE INSURED) DATE OF MAILING: 05/04!11 NAME AND ADDRESS OF AGENT BROKER: Morstan General Agency Inc Hickey-Finn & Co Inc P.O.Box 4500 15 Davis Avenue Manhasset NY 11030-0500 Poughkeepsie NY 12603 (Specific information concerning the cancellation or nonrenewal has been given to the Insured.) TO CERTIFICATE HOLDER: You are notified that the above policy is cancelled or nonrenewed effective on and after the hour and date mentioned above. This notice is being provided to you as you have been provided with a certificate of insurance on the above policy. Any interest you may have in the above policy is terminated. NAME AND ADDRESS OF CERTIFICATE HOLDER Town of Wappinger 20 Middle Bush Rd Wappingers Falls NY 12590 ~~ ~ ~, ` . " AUTHORIZED REPRESENTATIVE ~~~~~i~~/~~~ MAY 0 6 2011 (E)GU 323k (Ed. 8-06) UNIFORM 't"''a , CERTIFICATE HOLDER'S COPY Page 1 of 1 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY POLICY NUMBER 'tiA 1212 777-5 12590 :~:~:~A~€2ff).E1:~EC31l~R~I~:~$Y>?WIC:~Ir~€~'fIF:ECAF'~~:~:~:~>:~:~:~:~: POLICYHOLDER TIMBER CREEK HOMES 87 DIDDELL ROAD WAPPINGERS FALLS INC NY 125906227 DATE 4/26/2011 CERTIFICATE NUMBER 649-224 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1212 777-5 UNTIL 8/05/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 8/05/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~~ ~9 GHTS >~~ MAY ~ ~ ?e11 T O L`~lll~ ~~~-~ g~~,Ffl ~~ ER ~~ _~~ THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 1565 CERT02-2/2001 NEW YORK STATE INSURANCE 199 CHURCH STREET NEW YORK N.Y. 1-8$8-997-3863 CERTIFICATE OF WORKERS' COMPENSATION TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ...................................:.:............:............. ~:.:: ~ i?~RiQf~:. G01f~R~D:. $Y 51~HIS:.>rC-~T:Ii=:1C~ti':>:.:.:.:.::: ~: ~: POLICYHOLDER T W F CONTRACTING INC 211 CHESTNUT STREET PORT CHESTER NY 105733122 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +G 1243 153-2 DATE 4/27/2011 CERTIFICATE NUMBER 906-691 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1243 153-2 UNTIL 6/29/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 6/29/2011 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. AND CONFERS NO RIGHTS CERTI I E DOES NOT ~C ~ ~ ~~ ~~/tea, ~.~~ vi•=:~ !) <~~-. ; ~ l,~ ,_~~ ~~ '~~!3r `-- t~~y ~ ~j4`i ~`~~ ~.+~" THE STATE INSURANCE FU~QD ~~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 2643 CERT02-2/2001 FUND 10007-1100 INSURANCE NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8~8-997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS FALLS NY 12590 :~:~:~P~€t1Qf3:~E011~R~b:~$Y:~`~WIS:~C~f{?IK:ECA'C~~:~:~:~:~:<~:~:=: POLICYHOLDER T W F CONTRACTING INC 211 CHESTNUT STREET PORT CHESTER NY 105733122 POLICY NUMBER +G 1243 153-2 DATE 4/27/2011 CERTIFICATE NUMBER 292-653 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1243 153-2 UNTIL 6/29/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 6/29/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS N RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICAT D NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. O '~~ .~ p U-26.3 9y ~ ~~.~~ ~ j~o, ~ ., . ~,~ F THE STATE INSURANCE~~'FD ~Q '~ ~~J . - DIRECTOR, INSURANCE FUND UNDERWRITING 2705 cFRTn~-~i~nni Technology Insurance Company 5800 Lombardo Center Cleveland OH 44131-2550 CERTIFICATE HOLDER NOTICE NEW YORK WORKERS COMPENSATION INSURANCE COVERAGE Certificate Holder: Town of Wappinger 20 Middlebush Road Wappinger Falis, NY 12590 Insured: Commercial Contracting Company, Inc. Policy Number: TWC3267826 Policy Period: 12/31/2010 to 5/11/2011 12:01 a.m. at the insured's mailing address Date of Notice: 4/27/2011 Notice Type: Cancellation Effective Date of Cancellation: 5/11/2011 12:01 a.m. at the insured's mailing address Endorsement No.: 5 Reason: Prem Due 3379.00 As a Certificate Holder on the above policy, you are hereby notified that in accordance with the terms and conditions of this policy, Workers' Compensation Insurance will cease on the date shown for the above named insured. If you have any questions regarding this notice, please contact the insured listed above. '=-~' t By: ,• Technology Insurance Company An AmTrust Financial Company A member of the AmTrust Financial Group A.M. Best Rating: A- Authorized ~' ~\ <`~ U ~. ~%~ `~~ ~4 h; ~ ..~~ ~n ~` T~l~~~u ~~~y0 ` l (~~~~ a. r~, 1~ .~C~~~ I,~,~ ~~~ FR NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SION, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~:~:~f'C~€2iQE3:~Cd5t~R:~d:~BY>?wIS:~E~i~1I~iC,A't~~:~>:<~»>: ~:~: POLICYHOLDER TIMBER CREEK HOMES 87 DIDDELL ROAD WAPPINGERS FALLS INC NY 125906227 POLICY NUMBER *A 1212 777-5 DATE 4/26/2011 CERTIFICATE NUMBER 921-331 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0.--1212 777-5 UNTIL 8/05/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 8/05/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ON CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. T IS .'~ NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLI Y. ~~~~(~~ ` ~- . :~ Y,~, ~.~.~ ~ APR 2 9 2011 Tp ~N ~ ~ tNq ~~~~~ER ~~~~~~~ ~L~~K THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 1559 cFRrn~-~i~nni NEW YORK STAT~~I1E INSURANCE FUND 1 WATERVLIET AVENUE ~518)S4~N~6400ANY, NEW YORK 12206-1649 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER ATTN: BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY POLICYHOLDER TIMBER CREEK HOMES 87 DIDDELL ROAD WAPPINGERS FALLS 12590 :;.:.<p~i~za>co~i~o:~$v: tWi~`ir~€tr~~:cr~t~~>:~:~:~:~:~:: ;: :::::::::::;s~:o~~~~a9::::~~::::::~:toy'~:~ar~:::~:::::::::::~:::::::::~: CERTIFICATE HOLDER TOWN OF WAPPINGER ATTN: BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 INC NY 125906227 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0.-1212 777-5 UNTIL 8/05/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 8/05/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. ~: ;~ ..., P R POLICY NUMBER '~A 1212 777-5 DATE 4/26/2011 CERTIFICATE NUMBER 703-153 ~-~~r(~ D APR 2 9 2011 TOwN C~1= ~A1`A~~TN~ER ~~ ~`~ ~~-~RK U-26.3 THE STATE INSURANCE F~7RlT-- ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING 1569 r.FRTn~-~i~nn i NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS FALLS NY 12590 ~: ~:.:~:`• 1?~~#fQE3:. EC71f~R~ti:: ~3Y:, tWiS:.~~f~TI~:EGa7i'::.:.:.:.: ~:.>:~::: POLICYHOLDER T W F CONTRACTING INC 211 CHESTNUT STREET PORT CHESTER NY 105733122 POLICY NUMBER +G 1243 153-2 DATE 4/27/2011 CERTIFICATE NUMBER 337-133 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1243 153-2 UNTIL 6/29/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 6/29/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~ ~ AND CONFERS NO RIGHTS CERTIFICATE DOES NOT D APR 2 9 z011 TOwN QF IN~~P;~~~ER THE STATE INSURANC~Fi~£ ...~~~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 2699 CERT02-2/2001 New York State Insurance Fund Workers' Cornpensutio~r & Disability Benefits Specialists Since 1914 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 Phone: (888)997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 141793765 KEEVILY,5PER0-WHITELAW INC. 500 MAMARONECK AVENUE HARRISON NY 10528 POLICYHOLDER CERTIFICATE HOLDER STAR GAS PRODUCTS INC _ TOWN OF WAPPINGER 33 FULTON ST 20 MIDDLEBUSH ROAD POUGHKEEPSIE NY 12601 WAPPINGER FALLS NY 12590 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE G 1068 146-8 519715 05/01/2010 TO 05101 /2012 4/28/2011 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1068 146-8 UNTIL 05/01/2012, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER TFIE NEW YORK WORKERS' •COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT A5 INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 05!0112012 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL 50 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. APR 2 9 2011 TOWN OF 'WAPPINGER TOW4~ CLERK NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https:/lwww,nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 841544992 U-26.3 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE F~XTENSION, ALBANY, NEW YORK 12206-1649 1518)) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER FALLS 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 ::~::pC~iQE3:~E011~RE1~:~8Y:~~`WIC:~~C~'~IF:FG;43~~:~:~:~:~:~:~:~: ~:~: POLICYHOLDER TIMBER CREEK HOMES 87 DIDDELL ROAD WAPPINGERS FALLS INC NY 125906227 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1212 777-5 UNTIL 8/05/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 8/05/2011 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 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. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. POLICY NUMBER *A 1212 777-5 DATE 4/26/2011 CERTIFICATE NUMBER 921-142 CERTIFICATE HOLDER TOWN OF WAPPINGER FALLS 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 G°,3[~C~C~~~9f~~ ~~~ APR 2 S 2011 y TOWN OF WgppINGER TOWN CLERK THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING ~~7 rcoTn~_~i~nn+ New York State Insurance Fund Workers' Compensation & Disability Benefits Specialists Since 1914 1 WATERVLIET AVENUE ALBANY, NEW YORK 12206-1649 Phone: (518) 437-8400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^ " ^ " ^ ^ 89527334 MATTHEW J VOLK 486 SCHULTZ HILL ROAD RHINEBECK NY 12572 POLICYHOLDER MATTHEW J YOLK 486 SCHULTZ HILL ROAD RHINEBECK NY 12572 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH RD. WAPPINGERS NY 12590 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE A 1140 970-3 506973 03/02/2011 TO 03/02/2012 4/19/2011 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY N0. 1140 970-3 UNTIL 03/02/2012, 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 03/02/2012 1N 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 POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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. ~~ ~~~~~~ T~ qPR 2 0 ~ ~U wN ~~, 2011 ~0~,,~'~ ~ ~`'.~ pplN ._ ~~~~kG~R ~ NEW YORK STATE INSURANCE FUND xrn~~ ~~ DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 217535892 U-26.3 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) lb. Business Telephone Number of Insured 732-568-9000 Geomatrix Services, Inc. 210 East High Street lc. NYS Unemployment Insurance Employer Bound Brook, NJ 08805-2004 Registration Number of Insured 47-23835-1 ld. Federal Employer Identification Number of Insured Work Location of Insured (Only required if coverage is speciftcally or Social Security Number limited to certain locations in New York State, i.e., a Wrap-Up 22-3656248 Policy) 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) New Hampshire Ins. Co. Town of Wappinger 3b. Policy Number of entity listed in box "la" 20 Middlebush Road W0005-30-3027 Wappingers Falls, NY 12590-4004 3c. Policy effective period 10/04/10 to 10/04/11 3d. The Proprietor, Partners or Executive Officers are ® included. (Only check boz if all partners/officers included) ^ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NI') must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notes the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until thepolicy expiration date listed in box "3c", whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent above and that the named insured has the coverage as depicted on this form. Approved by: Approved by: Title: the it~~i~~ac~~~f~~l APR 1 8 2011 (Print name of authorized representative or licensed agent of insurance (Date) ~~fOWlV OF l~Z~PPINGER Tr,1n,/l,l r. ARK ~~ Y .~+°, x, Telephone Number of authorized representative or licensed agent of insurance carrier: 973-435-3311 ` Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-07) '> J Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. ~, v,~, .-=- APR 1 8 2011 TOW~f ~~ ~vl~~~PINGER T01~~~f~ CL~R~ Workers' Compensation Law C-105.2 (9-07) Reverse NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~iSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER ATTN: BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~::~PC~€21QE3:~EC~t~R~D:~$Y:~?WIC:~C~€~?'IF:EGA~'~~:~:~:~:~:~:~>:~: :~:~:::~::8~0.~:1~~~9:~:~f~1~:~:~:~5~fo9:~~t~7t:~:~:~:~:~::~:::~:~:~: POLICYHOLDER TIMBER CREEK HOMES INC 87 DIDDELL ROAD WAPPINGERS FALLS NY 125906227 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 5/09/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 POLICY NUMBER +A 1212 777-5 DATE 4/19/2011 CERTIFICATE NUMBER 703-153 CERTIFICATE HOLDER TOWN OF WAPPINGER ATTN: BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 I r' .~ , D L APR 2 z 2011 TOwN G~ V~~P,PjNG ~~VV~V CLERK ER THE STATE INSURANCE FUND c} ~ DIRECTOR, INSURANCE FUND UNDERWRITING 667 cTnrn~i-~i~nn i NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 :~:~::p~1<7E3:~Ed1l~R~CS>SY>1~WIl:~~~t~1IF:{Gat:~~>:~:~>:~:~: >:~: ::::::::::~~:o~~~~o.~:::~c~::::::;5:tog«ar~ ::::::::::::::::::::::::::: POLICYHOLDER TIMBER CREEK HOMES INC 87 DIDDELL ROAD WAPPINGERS FALLS NY 125906227 POLICY NUMBER +A 1212 777-5 DATE 4/19/2011 CERTIFICATE NUMBER 649-224 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 5/09/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. A ~ ~~~~ ~ ~ ~ _` _ ~, ~~ ,~ APR 21 2Ci1 T O w~ CAF' I~~/,~ ~~~~G 7'p`--~-~~~ K ER CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~~ - ' _ DIRECTOR, INSURANCE FUND UNDERWRITING 665 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~:~:~R~Et1QE1:~CC31t~R~D:~$Y:~?kl1a:~ir~F#~IF:fGAT'f :~:~:~:~:~:~:~:~:~: POLICYHOLDER TIMBER CREEK HOMES INC 87 DIDDELL ROAD WAPPINGERS FALLS NY 125906227 POLICY NUMBER +A 1212 777-5 DATE 4/19/2011 CERTIFICATE NUMBER 921-331 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 5/09/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. CANCELLATION U-26.3 ,-~ x ~~ ,~, ~~ ~~ _ AP ~"~ R 21 2011 ~-~ ~ ~~~~~ER THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING 657 c-rnr nni_^~in nn, NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER FALLS 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 ~:~::~AC~€2iQE3:~EC3Sf~R~ti:~$Y: tWi5Sr~f2I'I~:FGA7~~:~:~::`•::`•:::~: POLICYHOLDER TIMBER CREEK HOMES INC 87 DIDDELL ROAD WAPPINGERS FALLS NY 125906227 POLICY NUMBER +A 1212 777-5 DATE 4/19/2011 CERTIFICATE NUMBER 921-142 CERTIFICATE HOLDER TOWN OF WAPPINGER FALLS 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 5/09/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERT DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. CANCELLATION U-26.3 " ~~ ~~,- ~_ ~ .. R21 TOE ~ AP 2011 Tp ~.~`', ~'rf`~~l ~~'~ {~";~ ~ ~~ER THE STATE INSURANCE FUND d-Q~ DIRECTOR, INSURANCE FUND UNDERWRITING 183 c-rnrnni-~»nn i NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :::::`1?~1QEi:~E01l~R~d:~$Y:~ TH15:~~~E~?I~:FG;4T~~>:~:~:~:~:~:~:~: POLICYHOLDER T W F CONTRACTING INC 211 CHESTNUT STREET PORT CHESTER NY 105733122 POLICY NUMBER +G 1243 153-2 DATE 4/18/2011 CERTIFICATE NUMBER 906-691 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 5/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~, CANCELLATION U-26.3 •~~ v U ~ M, ~~£F ~ `~ ~~ ~ ~~ ~ ~Tp qPR 21 ? ~' N of -~ ~~~ C)~rt/ ~~'~~r _. ~~ c~ ~~ ~~FR ._ ~ ~ THE STATE INSURANCE FUND ~~~~- DIRECTOR, INSURANCE FUND UNDERWRITING 1835 ~T~~ ,,,,, ., ,.,,,,. , NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~>AC,€tffld:~EC31t~I~~ti:~8`/:~?WI~:~~~€~TIK:IC;4T~~: >:::=:~:~:~: POLICYHOLDER T W F CONTRACTING INC 211 CHESTNUT STREET PORT CHESTER NY 105733122 POLICY NUMBER +G 1243 153-2 DATE 4/18/2011 CERTIFICATE NUMBER 337-133 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 5/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERT KATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. /~, CANCELLATION U-26.3 _,,~. ~' AP ~/vS~~~~ Tod R21 '~ e~ ~~fiR __~ THE S_T/A~TE INSURANCE FUND <~ ~/ ~ Q DIRECTOR, INSURANCE FUND UNDERWRITING 6495 ~T,,,-„~~_ ~,~..~ , NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~:~:~:~A~€tiQ~:~C01t~a~d`$Y`?HIS:~C~€t:TIF:~C:At~~:~':`•>:~:~>:~:~: POLICYHOLDER T W F CONTRACTING INC 211 CHESTNUT STREET PORT CHESTER NY 105733122 CERTIFICATE HOLDER POLICY NUMBER +G 1243 153-2 DATE 4/18/2011 CERTIFICATE NUMBER 292-653 TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 5/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CE FICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. /~~~ O ~~~~ ''~~~I qp ~ ~~~~ 0 rod RZI N C~~ 2~,/ ~~ 2 ~~ CANCELLATION U-26.3 THE STATE INSUtRANCE FUND d v~ DIRECTOR, INSURANCE FUND UNDERWRITING 6477 I~ STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name and address of Insured (Use street address only) lb. Business Telephone Number of Insured Bridge View Excavation Inc. 845-226-3060 lc. NYS Unemployment Insurance Employer Registration Number of Insured 3 Van Wyck Lane Suite 1 4661561 Wappingers Falls NY 12590 ld. Federal Employer Identification Number of Insured or Social Security Number 141772459 Work Location of Insured (Only required if coverage is specifically limi-ed to certain locations in New York State, i.e. a Wrap-Up Policy) 2 Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Technology Insurance Company Town of Wappingers 3b. Policy Nrunber of entity listed in box "la": 20 Middlebush Road TWC3277701 3c. Policy effective period: Wappingers Falls NY 12590 4/1/2011 to 4/1/2012 3d. The Proprietor, Partners or Executive Officers are: included. (Only check box if alt partnerslofficers included) all excluded or certain partners/officers a:eluded. _~_.._ :_ ~..... «,a„ Fnr.vnrlrerc' comcensation This certifies that the insurance carrier indicated above in box "3° insures me ousurosa .~.~~~~~~~~ ~--•- •-• ---- -- under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ojprenriums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agen-, or until the policv expiration date listed in box " 3c", whichever is earlier. it the business continues to be named on a Please Note: Upoa the cancellation of the workers' compensatfon policy indicated on this form, permit, license or contract issued by a certificate holder, the business must provide that certificate holder with s new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, l certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. ~- , Approved by: Approved by: Henry C. Sibley (Print name of authorized representative or licensed agent of insurance carrier) y~::x, ~ %1:~; 4/11/2011 ., (Signature) Title: Underwriting Manager (Date) Telephone Number of authorized representative or licensed agent of insurance carrier 607-724-0173 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. to issue it. C-105.2 (9-07) ,a -.... :,ti,~: ~, Insurance brokers are NOT authorized v ~_~. ~C v'-~~ ' v lair: 1 ~ ;,. ~~ TOUif f~ ~~~ ~~i ~a~if~GER TOWN CLERK 1 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proaf duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-07) Reverse NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1448 745-8 DATE 4/04/2011 CERTIFICATE NUMBER 368-565 :~`RE_€2iO(3:~COV~R~b>8Y>tW1iS:~C~f{TI~:ECa~~~:~>:~':~>::~:~: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 4/24/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE P0~ CANCELLATION U-26.3 ONLY AND CONFERS NO RIGHTS THIS CERTIFICATE DOES NOT G°~ ,~~'~~~n~D APR 0 8 2G`~i T C.3.t~ro~ ~~~._ ~..e_ ,~ ~_ K_____ THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING RF,7 NEW YORK STATU~TTE INSURANCE FUND 1 WATERVLIET AVENUE ~518)54~N~6400ANY, NEW YORK 12206-1649 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE WAPPINGERS FALLS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~: ~ 5.'•R~iiQEi>EC3~R~d: ~flY:~'T.W1~:`•C~Ft~IF:{G;4T~>: ~: ~":~:~': ~: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 POLICY NUMBER +A 1448 745-8 DATE 4/04/2011 CERTIFICATE NUMBER 174-621 CERTIFICATE HOLDER WAPPINGERS FALLS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 4/24/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATF~OES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~ ~~ O `C 4 ~ ~~ o ~~ <. ~' ,~~ ~2 '~`~ ~~ / CANCELLATION U-26.3 THE STATE IN RAN FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING oon NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 .•:•:•P.C~21QE~>EO\1Sf~ECS:~$Y: tHIS:~CE€tl:l~:{CATP~:~:~:~:~:~:~:~:=:~: ::::::::::~~z~~~~:as=::~~::::::¢:fz~i:~~r~ ::::::::::::::::::::::::::: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 POLICY NUMBER +A 1448 745-8 DATE 4/04/2011 CERTIFICATE NUMBER 526-941 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 4/24/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. _ CANCELLATION U-26.3 ~~ ~~ li' ~pR ~o a, -~.,.. r ~. yy~ GER --~., THE STATE INSURANCE DIRECTOR, INSURANCE FUND UNDERWRITING 833 STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE EXTENSION, ALBANY, NEW YORK 12206-1649 (1518)) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 •:•:•:•RL~t1QE3>EC31f~REb:~$Y>?Hlts:~C~R'EIF:~C,4TP~:~>:~:~;:~:~.`•:~: ::::::::::~~z~~~~r~~:::~~::::::4:tz~~ar~ ::::::::::::::::::::::::::: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 POLICY NUMBER +A 1448 745-8 DATE 4/04/2011 CERTIFICATE NUMBER 175-923 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 4/24/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICAT ES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. < ~. CANCELLATION U-26.3 -~~ ~, ~~~ ~~~~D APR TO ~/N 0 7 2011 ~~ ~~If F ~``~ ~~~~G ~ ~~ERK ER THE STATE INS UNI ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 891 STDCAN- 2 /7 f1f11 STATE OF NEW YORK ~ WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE lb. Business Telephone Number of Insured le. Legal Name and address of Insured (Use street address only) 945-221-9412 Metzger Construction Corp & Glen P Metzger Dba: Metzger Construction lc. NYS Unemployment Insurance Employer 3 Van Wyek Lane, SUlte 1 Registration Number of Insured 20.90579 Wappingers Falls NY 12590 t d. Federal Employer Identification Number of Insured or Social Security Number 161526018 Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, i.e. a Wrap-Up Policy) 2. Name and Address of the Entity Requesting Praof of Coverage (Entity Being Listed as the Certificate Holder) Town of Wappinger Building Department PO Box 324 Wappingers Fars NY ~~~ ~ ~~ ,-- ~- ~ D APR 11 20 i1 i~ ~~ ~+~~~PII~IGER 3e. Name of Insurance Carrier Technology Insurance Company 3b. Policy Number of entity listed in box "la": TWC3277700 3c. Policy effective period: 4/1 /2011 to 4i1 /2012 3d. The Proprietor, Partners or Executive Officers are: included. (fly check box if all paRners/ollicers rrrcluded) I ~ all excluded or certain partnersloflicersaxcluded. F This certifies that the insure ce carrier i~~t~~~oy -tax"-"-3 ~ s e business referenced above in box "la" for workers' compensa ion under the New York State peniiation Law. (To use this form. New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also notify the above certiJcate holder within 10 days IF a policy is canceled due to -ronpayment of premiums or within 30 days IF there are reaso-rs other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated o-r this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after ti»s form is npproved by the insurance carrier or its licensed agen-, or until the policy expiration date listed in box "3c", whichever is earlier. Please Note: Upoa the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Henry C. Sibley (Print name of authorized representative or licensed agent of insurance carrier) y~.;:~ d• ~~.~; 417/2011 Approved by: (Date) (Signature) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance carrier 607-724-0173 Please Note: Only insurance carriers and their licensed agents are authorized to issue ilre C:-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2 (9-07) Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in cennection with any work involvnna statutepeo airing or authorizing the issue of suchppermits tshall no tissue su hppermit unless th nsation for all employees as notwithstanding any general or spec q proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, at compe been secured as provided by this chaptecArmtnit~ion or office to pay•an col mpensation~to any such employeelif sso a ploy~of such state or municipal department, board, 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-07) Reverse STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address ib. Business Telephone Number of Insured only) 845-471-9494 Wilson Electric Inc. D 1c. NYS Unemployment Insurance Employer . 188 Cottage Street Registration Number of Insured Poughkeepsie, NY 12601 11-504873 1d. Federal Employer Identification Number of Work Location of Insured (Only required if coverage is Insured or Social Security Number specifically limited to certain locations in New York State, 14-1631868 i.e., a Wrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Hartford Insurance 3b. Policy Number of entity listed in box "1a" Town of Wappingers 16WECJY2661 20 Middlebush Road Wappingers Falls, NY 12590 3c. Policy effective period 04/01/11 to 04/01/12 3d. The Proprietor, Partners or Executive Officers are X included. (Only check box if all partners/officers included) all excluded or certain partners/officers Excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices maybe sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent or until the policy expiration date listed in box "3c'; whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Daniel Hickev sr. (Print name of authorized representative or Approved by: (Signature) nsed agent of insurance carrier) ~~ Title: ~` `{s-~~~~~ Telephone Number of authorized representative or licensed agent of insurance carrier: Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. it. C-105.2 (9-07) ~~~® TpW~/ APR ~ 1 20>> nn ° V ~I I~ _ Ik~~!~~rV~Q ~p~ ........_ ~R~ ~~'` ^, Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duty subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-07) Reverse P ~~~ ~~~~o APR To wN ~ ° 1 zo>> PTO ~,~ ~~'~ ~~jNG ~~E~K ER STATE OF NEW YORK WORKERS' COMPENSATION BOARD n~oT~rine-rG nG NVC Wr1RKFRS' C[~MPENSATION INSURANCE COVERAGE ..~... 1a. Legal Name 8 Address of Insured (Use street 1b. Business Telephone Number of Insured address only) (585) 647-6400 Monro Muffler Brake, Inc. 200 Holleder Parkway 1c. NYS Unemployment Insurance Employer Rochester, NY 14615-3808 Registration Number of Insured 43403512 Work Location of Insured (Only required if 1d. Federal Employer Identification Number of coverage is specifically limited to certain locations Insured or Social Security Number in New York State, i.e., a Wrap-Up Policy) 16-0838627 2. Name and Address of the Entity Requesting 3a. Name of Insurance Carrier Proof of Coverage (Entity Being Listed as the The Charter Oak Fire Insurance Company Certificate Holder) 3b. Policy Number of entity listed in box "1 a" Town of Wappinger TC20-UB-177D815-0-10 20 Middlebush Raad Wappingers Falls, NY 12590 3c. Policy effective period 04-01-2011 to 04-01-2012 3d. The Proprietor, Partners or Executive Officers are ® included. (Only check box if all partnerslofficers included) ^ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "1 a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices maybe sent by regular mail). Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box "3c ", whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, 1 certify that I am an authorized representative or licensed agent of the ~surance carrier referenced above and that the named insured has the coverage as depicted on this form.;.' i Approved by: Approved by: Dee Belleville / (Print name of~ uthorized representative or licensed agent of insurance carrier)/ nl 122 ~ ~ ._ ., ~4 1G < ~ ~+., Title: Account Telephone Number of authorized representative or licensed agent of ii Please Note: Only insurance carriers and their licensed agents are brokers are NOT authorized to issue it. ~ C-105.2 (9-07) www.web.state.ny.us (Date) ~` authorized ~~s e Form C-105.2. 1 surar T0~/ 12011 7'O ~~ ~'~`~~~~N -"~~ 31 F3J07 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~VSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 :::::::::1?C~€i1QE3:: E C31l~i2~D:: f3Y::1'W I~:;lr~€~1`IF:FG;4~f::::::::::`•>::::::: ::~:~:~:~::fob:o~:l~~~r6::::t`[~:~:::::4.:fo.412¢x~ :::::::::::::~:::::::::=::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER '~A 1465 188-9 DATE 3/31/2011 CERTIFICATE NUMBER 758-168 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. G°~C~~~~~~~D APR 0 4 Za11 ;ti #~ ~7'OWN ~ = ~~~''~t~'PINGF~ THE STATE INSr(URANCE FUND d-~~ U-2G.3 DIRECTOR, INSURANCE FUND UNDERWRITING 907 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~iSION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~:~A~€iiQEti:~CO~RE~>$1!:~tHi~:~C~€~tIF:~C.~~t~~>:~:~':~:~`>.'•: :~::::::::::~>r:oa~~~:~:::~'~::::::a:foaE:~arz :::::::::::::::::::::::::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER '`A 1465 188-9 DATE 3/31/2011 CERTIFICATE NUMBER 044-914 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 4/04/2012 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~C~tfU ~'~ <.~~~K THE STATE INSURANCE FUND d- v~-~-~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 323 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 POLICY NUMBER '`A 1465 188-9 DATE 3/31/2011 CERTIFICATE NUMBER 997-535 ?~>:~RC~€i]bd:~EC31f~REb>$`~:~TW15>C~€~l'I~:EC;4TB :~»:~:~:~::~:~: ~~~:~:~:~>~4:~~:04~1~~~9:~:~~1~``:~4:f04f~1~~~~::::":~:~:~:~:~::~`: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 IN SUCH MANNER AS J 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. ~V' ~ ~ V ~ L_,i -- -- U-26.3 ,_, -~~ ~' APR 0 4 2011 _.~..~'~~ll/RI CLEF .. . THE STATE INSURANCE FUND ~~ _ DIRECTOR, INSURANCE FUND UNDERWRITING 927 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICY NUMBER '~A 1465 188-9 DATE 3/31/2011 CERTIFICATE NUMBER 146-040 :~`>AC-~tiQE3:~60~i~~D`BY:~TWI~:~~~r~~I~:ECa7f~:~`:~:~:~`:~.'•`: ::::::::::~~~a~~~~r8::::~'c~:>:4:f>~~~~~2 ::::::::::::::::::::::::::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. U-26.3 ~CC~~~~~(~ -~. ~~ VD ~~ APR 042011 TO~,r~ ~?~ Vi~gPPIN~~~.~ ~'~~r~~~~ ALE THE STATE IN~T7]lt~dEUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING 929 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 ~:~:~>1?~€t1f1E3>E01l~REd: ~f3Y:~~WIS:~C~E2TIK:ECA7~~:~:~:~:~:~:~>:~:~: ::::::::::d~:oa.:~~~a8::::~~::::::Q:fad«vr2 :::::::::::::::::::::::::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER *A 1465 188-9 DATE 3/31/2011 CERTIFICATE NUMBER 347-553 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. ~~~ v ~l ~a APR 0 4 2011 TOWN Q~' WF~P~Ii~GER ,~/ 1~iJ~l FU U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 941 CERT02-2/2001 New York State Insurance Fund Workers' Compensation & Disability Benefits Specialists Since 1914 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 Phone: (888) 997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 141816204 LOVELL SAFETY MGMT CO., LLC 110 WILLIAM STREET 12TH FLR NEW YORK NY 10038 POLICYHOLDER CERTIFICATE HOLDER FOLKES HEATING, COOLING & BURNER TOWN OF WAPPINGER SERVICE INC 20 MIDDLEBUSH ROAD 850 ROUTE 9 WAPPINGERS FALLS NY 12590 FISHKILL NY 12524 ~~ POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE G 2046 911-0 698990 04/01 /2009 TO 04/01 /2012 12/29/2010 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2046 911-0 UNTIL 04/01/2012, 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. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 04/01/2012 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 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 POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. DUSTIN J FOLKES 1 OF 1 PRESIDENT OF FOLKES HEATING,000LING 8 BURNER SER VICE INC 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. ~ p' r a ~~~~, ~~,C~~~~I~D APR 0 4 2Gi1 / • ~~ ~~~~~~~OER TOV~I~ O~ ~v~~ NEW YORK STATE INSURANCE FUND ~o~~,~ U DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 1010072546 U-26.3 350/CD34696-20/1238 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE C la. Legal Name & Address of Insured (Use street address only) lb. Business Telephone Number of Insured AVELLO BROTHERS CONTRACTORS INC 845-454-3650 60 FULTON STREET le. NYS Unemployment Insurance Employer POUGHKEEPSIE, NY 12601 Registration Number of Insured Work Location ofinsured (Only reguiredifcoverageisspecifically id. Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e., a Wrap-Up or Social Security Number Policy) 14-1537061 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Bolder) NEW HAMPSHIRE INSURANCE TOWN OF WAPPiNGER 3b. Policy Number of entity listed in box "1 a" 20 MIDDLEBUSH ROAD ~ 51750655 WAPPINGERS FALLS, NY 12590 ____..._. 3c. Policy effective period .W_.._~_ ._ ~ (-~~ _, 'J rh- Lam/ ~ lJ 4/1/2011 4/1 /2012 to _ ~ l L~ ~J L~ I~ ~ 3d. The Proprietor, Partners or Executive Officers are APR 0 4 2011 ^ tncluded. (Only check box If a8 partnere/offlcers included) /Q all excluded or certain partners/offlcers excluded. TOWS! ~€~ VII~P°~3N~ER ~ ~~_ ~ ~~i'et.i~SA~ec~..a°bo`ue-.ixt--belt " 3" insures the business referenced above in box "1 a" for workers' This certifies the the insu afi g i compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under It m A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also note the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment ofpremiums that cancel the policy or eliminate the insured from the coverage indicated on dhis Certi, ficate. ('t'hese notices may be sent by regular mail.) Otherwise, this Certiftcate is valid for one year after this form 1 is approved by the Insurance carrier or its licensed agent, or until the policy expiration date listed in boz "3c'r, whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the busfness continues to be named on a permit, license or contract issaed by a certificate holder, the busfness must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the overage as depict on this form. Approved by: ~~~ ~ ~ t' ~ L ~-- - (Print am of tho 'zed representative or I' sed agent of insurance clarrier) J Approved by: f r (Signs (Date) Title: #~ 1 t'~ Telephone Number of authorized representative or licensed agent o urance carrier: ~ p U V ~7~-~ °~~~ Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.1. Insurance brokers are NOT authorized to issue it. C-105.2 (9-07) www.wcb.state,ny.us Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shat l not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contractunless proofduly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. [~[~C~~~~JCD APR 0 4 2011 T~~Ui~4 ~P UVAPPINC`mm'~`, ~"~UUN CLER~~. C-105.2 (9-07) Reverse NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +Z 1363 272-4 DATE 3/28/2011 CERTIFICATE NUMBER 121-471 :::.:.:.i~~€iiQI~:.Gd~R~1~:.~3Y:. tHiS:. C~€~1~IF:EC~ti7~ .:.:.:.:.:.:.:.:.:.: :::::::::t2~:o~~~~~:9:::~:~::::::4.f:~~~i~r~ ::::::::::::::::::::::::::: POLICYHOLDER PICCO CONSTRUCTION LLC 154 EAST BOSTON ROAD MAMARONECK NY 10543 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 4/17/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~L~C~I~~~~D APR 01 2011 ,v~.~ ., -- ~ TCVI/N Q~ ~~U1~PPIN~ER ~~'~~-~LEF~K THE STATE INSURANCE FUND CANCELLATION U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 14205 STI~CAN-2/20n 1 New York State Insurance Fund ___ __ __ Workers' Compensation & Disability Benefits Specialists Since I9I4 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 Phone: (888) 997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 141484873 LOVELL SAFETY MGMT CO., LLC 110 WILLIAM STREET 12TH FLR NEW YORK NY 10038 ', POLICYHOLDER CERTIFICATE HOLDER BLACK ELECTRIC INC I~, TOWN OF WAPPINGER ', 766 FREEDOM PLAINS ROAD ~, 20 MIDDLEBUSH RD POUGHKEEPSIE NY 12603 ~ WAPPINGERS FALLS NY 12590 i POLICY NUMBER i CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE I DATE G 2089 892-0 ~i 229530 04/01/2010 TO 04/01/2012 I 12/29/2010 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2089 892-0 UNTIL 04/01/2012, 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. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 04/01/2012 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 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. lf~l~ J J ~) MAR 2 0 2011 T®W1~ ~~ ~~~P~ ~ ER T~ ~a~_~~..EC~ __._- NEW YORK STATE INSURANCE FUND ~q~,~ U DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 600250902 U-26.3 350/CD34701-20 9 New York State Insurance Fund - _- _ _ - Workers' Compensation 8c Disability Benefits Speeialists Since 1914 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 Phone: (888) 997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 141724780 LOVELL SAFETY MGMT CO., LLC 110 WILLIAM STREET 12TH FLR NEW YORK NY 10038 POLICYHOLDER CERTIFICATE HOLDER ', BARON UTILITIES CORP TOWN OF WAPPINGER I 90 HARTS LANE I ' BUILDING DEPARTMENT ALBANY NY 12204 20 MIDDLEBUSH ROAD ~I WAPPINGERS FALLS NY 12590 G 2027 250-6 _ _ - -- _ -- -- - - -- - -- - - - ------ i, POLICY NUMBER ~i CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE 182512 05101 /2008 TO 04/01 /2012 ~~ 12/29/2010 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2027 250-6 UNTIL 04/01/2012, 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. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 04/01/2012 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 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. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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. r ---`__ r ~ ~_- ~ f--~~ '1 r--, ~~~~~~ n I,~ ~ r , _ 1 ~` ~~ .`.7 -'' ---7 i_i l4j ~.~ =J MAR 2 0 2~'1 NEW YORK STATE INSURANCE FUND ~q~,, U DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 496331200 U-26.3 350/CD34695-20/879 New York State Insurance Fund Workers' Compensation & Disability Benefits Specialists Since 1914 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 Phone: (888) 997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^ ^ ^ ^ ^ ^ 61426382 LOVELL SAFETY MGMT CO., LLC 110 WILLIAM STREET 12TH FLR NEW YORK NY 10038 POLICYHOLDER ~ CERTIFICATE HOLDER ~ JASTINE CONTRACTING CORP 'I ; TOWN OF WAPPINGERS FALLS ~ 8 APPLE SUMMIT LANE '. BUILDING DEPARTMENT '~ ~ LAGRANGEVILLE NY 12540 ' 20 MIDDLE BUSH ROAD '~ 'i WAPPINGERS FALLS NY 12590 r___. -- POLICY NUMBER 1 CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE ~ G 1479.618-9 850030 04/01 /2009 TO 04/01 /2012 12/29/2010 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1479 618-9 UNTIL 04/01/2012, 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. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 04/01/2012 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 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. 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. ;- "- ~.;: MAR 2 p ~,-~ <~ ,... NEW YORK STATE INSURANCE FUND ~q~,~ U DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 332548590 U-26.3 350/CD34691-ZO/743 New York State Insurance Fund Workers' Compensation & Disability Benefits Specialists Since 1914 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 Phone: (888) 997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 61533029 LOVELL SAFETY MGMT CO., LLC 110 WILLIAM STREET 12TH FLR NEW YORK NY 10038 POLICYHOLDER LISIKATOS CONSTRUCTION INC P.O. BOX 309 COLD SPRING NY 10516 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICY NUMBER '~ CERTIFICATE NUMBER G 1416 145-9 ~ 304122 PERIOD COVERED BY THIS CERTIFICATE DATE 04/01 /2010 TO 04/01 /2012 ~i 12/29/2010 ~ THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1416145-9 UNTIL 04/01/2012, 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. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 04/01/2012 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 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. ,_ J MAR20~~;'1 T®~,r , ~ .~ e , NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 369580153 U-26.3 350/CD34682-20/1433 Technology Insurance Company 5800 Lombardo Center Cleveland OH 44131-2550 CERTIFICATE HOLDER NOTICE NEW YORK WORKERS COMPENSATION INSURANCE COVERAGE Certificate Holder: Town of Wappinger 20 Middlebush Road Wappinger Falls, NY 12590 Insured: Commercial Contracting Company, Inc. Policy Number: TWC3267826 Policy Period: 12/31/201C to 12/1/2011 12:01 a.m. at the insured's mailing addresa Date of Notice: 3/11/2011 Notice Type: Reinstatement Endorsement No.: 2 Reason: As a Certificate Holder on the above policy, you are hereby notified that the NOTICE OF CANCELLATION effective 3/1012011 is superseded. Coverage has been reinstated without lapse for the policy period noted above. If you have any questions regarding this notice, please contact the insured. sy: ~~ Authorized ,• Technology Insurance Company An AmTrust Financial Company A member of the AmTrust Financial Group A. M. Best Rating: A- ~~~~ ~n1~~ir-~~ MAR 2 0 2C TOV4IN C.~~ ~~,~t~~~iIV~ER TOV1/f~ ~LE~Z~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SION, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 ::~:~:~PC-~iQE3:~CC3u~RECi::f3Y:~1~WI~::C~r{II~:FCaT~:>:::~:~::::::: ~::: :~::~:~:~::~:~:04~1~~1J8:~:~~f#:~:~:~4:fA~tl~~~Yt:~:~:~:::~:~:~:~:~:~:~:=::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER '`A 1465 188-9 DATE 3/10/2011 CERTIFICATE NUMBER 347-553 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 4/04/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDEN AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED B TH RIGHTS ~~I~~TE OES NOT MAR 1 6 2011 TOWfV 0~= ~,~J~~,p~~:NGER TOW ~ ~L~RK ~,, ` ~` ~` ; .~_ CANCELLATION U-26.3 THE STATE INSURANCE ;FUND DIRECTOR, INSURANCE FUND UNDERWRITING 835 STnraN-~i~nn i NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE ~XTENSION, ALBANY, NEW YORK 12206-1649 518)) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 POLICY NUMBER ~~A 1465 188-9 DATE 3/10/2011 CERTIFICATE NUMBER 758-168 ::pC~1f~F1:~CC31l~I~Eb>f3Y:~1W1~>C~f{'~IF:4G;4tf~:~:~:~:~:~: ~:~: ~: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 4/04/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~" ` ~~~ ~ G°~CC~C~~MCD MAR 1 6 2011 CANCELLATION U-26.3 841 TOUI,oN G~... ~'~~~=PPINGER T~1~~~~ ~~ ERK THE STATE INSURANCE FUND ~4~ _'_ DIRECTOR, INSURANCE FUND UNDERWRITING CTf1/` A 1~1-'9 /'~l1/1 ~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~tSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :~>R~1QE3:~C(3V~REd:~$Y:~`CWIS:~~~€~~I~:tGA~*~~:~>:~:~:~:~>:~: :::::::~::~~:o~~~~a8:::~~::::::a:fo~~:~~r~:::::::< :::::::::::::::::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER ~~A 1465 188-9 DATE 3/10/2011 CERTIFICATE NUMBER 146-040 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 4/04/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE ,PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 ~~~~M~~ MAR 1 6 2011 .; ~ ~ TOWN OF ~,~.,~~PTNGER T®1NN ~~ERK THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING 847 STn~aN-~i~nn i NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (914 701-2120 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~: ~>:.:.i?E~€2iQEi:~CO~R~b:.BY: ~ 1Wits:~ it~~:~1~:1Gat~ ::.:.:.:.:.:.:.:.:.: POLICYHOLDER BLUE HAVEN POOLS NY INC 11 PADDOCK DRIVE - SUITE B CHESTER NY 10918 POLICY NUMBER +W 2082 626-9 DATE 3/10/2011 CERTIFICATE NUMBER 248-323 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/30/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~::_ _~ ~~ a~~o n. ",-_ 1 5 2011 ~° ~T .. ~~';°~ ~ FINGER CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING /.Z/.S NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 POLICY NUMBER '=A 1465 188-9 DATE 3/09/2011 CERTIFICATE NUMBER 347-553 :<:.:.:. A~iit~E>EC3~R~Ei:.BY tWi~:.C~€~T1~:{G;4~'~::.:.>:;:.:.: :::::::::~~~a~~~~:~:::~~::::::4:t~~:~i~r~ :::::::::::::::::::::::::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. r~ - ~_:__ G°~C~~~M[~D MAR 1 4 2011 TOWN OF WAPPIl~GER r°~ ~C~~N~I CLERK 'HE STATE INSURANCE FU ~~ IJ-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 549 ('FRT(1~-7/~nl11 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE FXTE~iSION, ALBANY, NEW YORK 12206-1649 518 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 POLICY NUMBER ''~A 1465 188-9 DATE 3/07/2011 CERTIFICATE NUMBER 758-168 :::.:.:,1?C~$QF3:.E(31t~R~b:.f3Y'tWiS:.~~€~~`I~:{C,A'ff ::.:.:.:.:.:.:.:.: .: :.:::>:::~0~:0:~:1~~a6.::::~'c~:::::4:fob'1.~r~X2 :::::::.::::::::::::::::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 4/04/2012 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. [~CC~[~~~IL~D U-26.3 MAR 1 4 2011 ~~ ~" ..~ • TOWN OF WAPPINGER T~11~N CLERK THE STATE INSURANCE FUND ._c~ _. "?L~_ DIRECTOR, INSURANCE FUND UNDERWRITING i~o NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER *A 1465 188-9 DATE 3/07/2011 CERTIFICATE NUMBER 044-914 :::>:~f?~€tfQa::EOl~REd>$Y> tWl~::~~€~TIF:FC.A'ff::~:::~:~>:~: ~::: ::::::::d:~:oa~~~:~~:::~~::::::a:f,oil:~~r2 :::::::::::::::::::::::::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. ~. , ~ MAR 1 4 2011 TQ1,NN C)F VV~iPPINGER ~~1~l~i CLERK G°~CC~C~~C~D THE STATE INSURANCE FUND ~J v~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 1~~ nrnTnn_ninnn+ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 12590 POLICY NUMBER '`A 1465 188-9 DATE 3/09/2011 CERTIFICATE NUMBER 146-040 :`•:~<RC~€t1QE3?E~.1l~R(=d: ~$Y:~ tWi~:~~~€tTIKiC.;47'f~:~:~:~:~':~:~:~:`•: CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. ~{ ~ ~~ -~~ yLJ~ MAR 1 4 2011 TOwN OF iNAP~jNGER ~~~t~~~ ~~~~~ THE STATE INSURAN~Fi~~ ~~~- U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 249 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 :~:~>RC~€2iQd>6011~R~b:~BY:~tWI~:~lr~t~'~I~:FG;4~~~:~:~:~:~:~:~:~:~:~: POLICYHOLDER HOFFMAN HOMES & SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS REMODELING NY 12590 POLICY NUMBER '~A 1465 188-9 DATE 3/09/2011 CERTIFICATE NUMBER 997-535 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. T ERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLI Y. ~~~; ~.,~ ~~ MAR 1 4 2Dii °~ ~ TO VlflV CAF ~~~ r~ ~. FLINGER -, ~-~~~~-, ~~ ~~ER- K -( THE STATE INSURANCE FUND ~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING ~~o NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE FXTE~TSION, ALBANY, NEW YORK 12206-1649 (1518)) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE -~ TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 >: ~ `i?~€ticza: ~ COrt~RE=d`f31!: ~ 1~Wil S C~F~:I'Ii=:FCA7f ~>: ~ `: ~ `:? ~: ~: ~: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER '`A 1465 188-9 DATE 3/09/2011 CERTIFICATE NUMBER 044-914 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOE AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~ ~rl~\~ ~D ~~~ JL ~, n ~ ~ MAR 1 4 c.~'1 '.. s _..~ TO~f N CAF ~~,PPINC THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 257 CERT02-2!2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 :~:~:~i?C~iQE3:~E0rt~R~Ei:~$1!?tWi~:~~~€~fiI~:IC.~iTf`~:`•':~: <:~:~:~: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER ~~A 1465 188-9 DATE 3/09/2011 CERTIFICATE NUMBER 758-168 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. (~CC~C~MCD .; ~ MAR 1 4 2011 ,~. ~` ~TOV-iy,~-f//~~~ ~F ~~~A~~'IdUGER i ate` ~.' V ~~w. ~, ~ P°a f~. THE STATE INSURANCE FUNI g r, U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 555 CERT02-2/2001 STATE OF NEW YORK .WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name and Address of Insured (Use street address only) lb. Business Telephone Number of Insured Siegrist & Sons Construction, Inc. (845)473-4177 dba Siegtist & Sons Construction, Inc. 6 Orchard Pl lc. NYS Unemployment Insurance Employer Registration Poughkeepsie, NY 12601-1912 Number of Insured ld. Federal Employer Identification Number of Insured or Work Location of Insured (Only required if coverage is specifically Social Security Number limited to certain locations in New York State, i.e. a Wrap-Up Policy) 260377397 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Befng Listed as the Certificate Holder) 3a. Name of Insurance Carrier Continental Indemnity Co. Town of Wappinger 20 Middlebush Road 3b. Policy Number of entity listed in box "la": Wappinger Falls, NY 12590 46-818207-O1-02 3c. Policy effective period: 09/13/10 ~ 09/13/11 3d. The Propietor, Partners or Executive Officers are: included. (Only check bo: If all partnert/ofticen included) ® all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated shove i~ her ~~a~ t..a. ao .~.,....._:____ __r_ _ compensation under the New York State Workers' Com ensation Law. ^ _..... ~~,~~~"~ "„`c,reeu above m oox ^ia" for workers' P (To use this form, New York (NY) must be listed under Item 3A on the INFORMATIONAL PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send the Certificate of Insurance to the entity listed above as the certi£cate holder in box " 2". The Insurance Carrier will also note the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is va/id for one year after this form is approved by the insurance carrier or Its licensed agent, or until the policy expiration date listed to box "3c", whichever fc narll r- Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this Form. Approved by: Chris LaManfia (Print name of authorized representative or licenced agent of insurance carrier) Approved by: Title: Authorized 03/09/2011 (~rgnatwe) Telephone Number of the authorized representative or licensed agent of insurance Please Note: Only insurance carriers and their licensed agents are authorized to issue the authorized to issue it C-105.2 (9-07) ` ~ v~ D (877)234-4424 form. I>~~rgg b~vk~~~e NOT TOWN OF 4/Vf~PPINGER T®"t~/I~ C~.ERK NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE FXTE~ISION, ALBANY, NEW YORK 12206-1649 ((518)) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 Y :: ~:::i?CEi1f?.E3::E01l~R~d::fi~Y:: mWI~: ~C~€~1`IF:EGA~'~~:::::~: ~::::::: ~: :~:~:~:~:~~~:04:1~~~J9:~:~~':~:~:~:~4:fa~l~f~7~~:~:~:~:~:~:~:~:~:~:~:~:~: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER *A 1465 188-9 DATE 3/07/2011 CERTIFICATE NUMBER 997-535 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. MAR 1 0 20; ~ TGwN aF 1N~PpINGER TOWN CL THE STA ~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 163 f CDT/~'J-7/'~!~/~~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 _... .. ." POLICY NUMBER *A 1465 188-9 DATE 3/07/2011 CERTIFICATE NUMBER 347-553 ~:~:~:~ AC,€21Qd:~EC31t~1?~b:~$Y:~'~FIIfs:~~~€~1'IF:EG;;9~7~~:~: ~: ~:~:~:~:~>: ~: :~:~:~:~:~~~:04.~1:~~~r8::~~[~:~:~::a:foal:~i~r2:::~:~:~:~:~:~:~:~:~:::::~: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. __ MAR 1 0 2011 TOWN OE WAPPINGER TrJ~~/I~ CLERK THE STATE INSURANCE FUND ~~ IJ-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 17~ r~oTn~_~i~nn~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :~'::::PC€2fQE3::E011~R~1~::f3Y:~ ~'W15: ~ C~Ft~IK:{GA7f:::':::`•::::::::::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 AND CONFERS NO RIGHTS CERTIFICATE DOES NOT THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1465 188-9 UNTIL 4/04/2012 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/04/2012 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. G°~(~C~~~MC~D 1 POLICY NUMBER ''°A 1465 188-9 DATE 3/07/2011 CERTIF-CATE NUMBER 146-040 MAR 1 ~ 2011 TOWN OE t~ti~~PINGER TOl,~l~ (;LEAK THE STATE INSURANCE FUND ~~ IJ-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 154 r~oTn~_~i~nn~ CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 NEW YORK STAT~~I1E INSURANCE FUND 1 WATERVLIET AVENUE ~518)54037~6400ANY, NEW YORK 12206-1649 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 :~>:.:.12~€2ifZE1:.ECSSf~R~~:.i~Y.`• tWi~:.c~i~~~>':ccat~ ::.:::::.:.:.:.:.:.: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER 'tiA 1465 188-9 DATE 3/08/2011 CERTIFICATE NUMBER 347-553 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 4/01/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~_ CANCELLATION U-26.3 ~~~ si~~~ D ,~ , ,. ,,t MAR ~ 1 2011 ~.:.. , TOWS ~;~ W~Pr'~INGEF T~~°~-~~ERK THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 1959 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :::.'•:::: PC-~#1QE)' E01t~REl~::BY::'1WIC::~~R71~:FGA7~ :::::::::::::::::::: :::::::~~:04~~~~:~:::~'c~::::4.tai:~:~i~y:t ::::::::::::::::::::::::::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER '~A 1465 188-9 DATE 3/08/2011 CERTIFICATE NUMBER 146-040 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 4/01/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 MAR 1 1 2011 TGwN ®F WAPPINGER TQW~ CLERK THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING aua NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ::::.>:. PC~€tiQE3:. E C3.rl~R~D:: f3Y:, tWi~:. ~fi~1'I1=:4G;4'.F~ ::.:.:.:.:.:.:.:.: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER 'A 1465 188-9 DATE 3/08/2011 CERTIFICATE NUMBER 044-914 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 4/01/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 [~(~~I~~~~D ~, MAR 1 1 2G?1 TOWN aP WAPPINGER T~W~~ ~LE~K THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING ~.o ~ NEW YORK STAT~iE INSURANCE FUND 1 WATERVLIET AVENUE ~5i8)S4~N-6400ANY, NEW YORK 12206-1649 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 5:::::`•R~Et1QE3:: EC31l~REl3>SY:~ tWl~:;~~€~~I~:~Gi~!'tf:::::::`:::`•>::::: >:::.:.:.:~t,a~:~~1;~~1r6:~':~:~:~::4.fob:{.~~r~:.:.:::_>:.::>:.:.:.:.: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE .4/01/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~~~OMCD ~ .~ MAR 1 1 2011 TOWN CF F~~P±~INGER ~~~~~ C~.ERK ------------------ CANCELLATION U-26.3 POLICY NUMBER *A 1465 188-9 DATE 3/08/2011 CERTIFICATE NUMBER 758-168 THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 19(5 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE ~518~54~716400ANY' NEW YORK 12206-1649 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 ::::.:.: _ i?C~€tiQE3:. E C~V~REd:. $Y:. tWi~:. ~~R?I~:{CA~~:>:.5:.:.>:::: _: :~:;::::~~:oa~~~~r9.::::~:~::::::a:tai:~:~~r~ ::::::::::::::::::::::::::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER ''~A 1465 188-9 DATE 3/08/2011 CERTIFICATE NUMBER 997-535 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 4/01/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 ~~~C~~M D ~~_ ~ ~ MAR 1 1 2611 TGw~ ~-~~'~ ~A1'P.INGER ~~~°~'~ ~L~~K THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING 199 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name >~ Address of Insured (Use street 1b. Business Telephone Number of Insured address only) (585) 647-6400 Monro Muffler Brake, Inc. 200 Holleder Parkway 1c. NYS Unemployment Insurance Employer Rochester, NY 14615-3808 Registration Number of Insured 43403512 Work Location of Insured (Only required if 1d. Federal Employer Identification Number of coverage is specifically limited to certain locations Insured or Social Security Number in New York State, i.e., a Wrap-Up Policy) 16-0838627 2. Name and Address of the Entity Requesting 3a. Name of Insurance Carrier Proof of Coverage (Entity Being Listed as the The Charter Oak Fire Insurance Company Certificate Holder) 3b. Policy Number of entity listed in box "1 a" Town of Wappinger TC20-UB-177D815-0-10 20 Middlebush Road Wappingers Falls, NY 12590 3c. Policy effective period 04-01-2011 to 04-01-2012 3d. The Proprietor, Partners or Executive Officers are ® Included. (Only check box if all partners/officers included) ^ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "1 a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices maybe sent by regular mail). Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or ifs licensed agent, or until the policy expiration date listed in box "3c", whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Dee Belleville (Print name of authorized repre~se~n?tative or licensed agent of insurance carrier/), Approved by: ~~ ~~~ 17 ~-~- `-~l ~~~ (Signature) (Date) Title: Account Representative Telephone Number of authorized representative or licensed agent of in ~ (860 277f-6542 Please Note: Only insurance carriers and their licensed agents are utho~i~~~, ss~ ~r,~U5.2. 1 surance brokers are NOT authorized to issue if. ,%`""``~, ~ ,- a L~ ~ LJ V ~C MAR 1 1 2011 TOWN OF W~PPING~ F3~o7 C-105.2 (9-07) www.web.state.ny.us TOWN CL.~~K ~~~~ .. ~ , , Oy STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name and Address of Insured (Use street address only) Siegrist & Sons Construction, Inc. dba Siegrist & Sons Construction, Inc. 6 Orchard Pl Poughkeepsie, NY 12601-1912 lb. Business Telephone Number of Insured (84573-4177 lc. NYS Unemployment Insurance Employer Registration Number of Insured ld. Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, i.e. a Wrap-Up Policy) 2. Name and Address of th Coverage (Entity Being Town of Vi'appinger 20 Middlebush Road Wappinger Falls, NY tedya~tlllffb~r~ D 0 MAR 1 0 2011 TOWN OF WAPPINGEI TOWN JERK 260377397 Name of Insurance Carrier Continental Indemnity Co. Policy Number of entity listed in box "la": 46-818207-01-02 Policy effective period: 09/13/10 ~ 04/12/11 3d. The Propietor, Partners or Executive Officers are: included. (Only check bo: if all parmerrtonicers Included) ® all excluded or certain partners/officers excluded. This certifies that the insurance carrier compensation under the New York State Item 3A on the INFORMATIONAL PAC agent will send the Certificate of Insure in box "3" insures the business referenced above in box "la" for workers' iensadon Law. (To use this form, New York (NY) must be listed under 's' compensation insurance policy). The Insurance Carrier or its licensed listed above as the certificate holder in box "2". The Insurance Carrier will also notify th ove tificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other th nt of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may gular mail.) Otherwise, this CerUJicate is valid jor one year after thisform is approved by the Insurance carrier or its licensed a or u l the policy explraNon date !!sled !n box "3c'; whichever is earlier. Please Note: Upon the cancellat' kern' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a der, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorj~r f e business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. •a ~ Under penalty of petj erti t I am an authorized representative of licensed agent of the insurance carrier referenced above and that the named insured has the co depicted on this form. Approved by: Chris LaMantia (Print name of authorized representative or licenced agent of insurance carrier) Approved by: . ~~ - 01/10/2011 (Signature) (Date) Title: Authorized Representative Telephone Number of the authorized representative or licensed agent of insurance carrier: (877)234-4424 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2 (9-07) STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name and address of Insured (Use street address only) 1 b. Business Telephone Number of Insured 518-371-1551 Royco Construction Management, LLC Clark Data Processing Corp lc. NYS Unemployment Insurance Employer Registration 92 River Road Number of Insured Summit, NJ 07901 1 d. Federal Employer Identification Number of Insured or Work Location of Insured (Only required if coverage is specifically Social Security Number limited to certain locations in New York State, i.e. a Wrap-Up 22-3692195 Policy) 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) The Phoenix Insurance Co Town of Wappingers 3b. Policy Number of entity listed in box "la": ^ Town Hall 5911X60711 ~~ ~~~~ " 20 Middlebush Road (( v Wappingers Falls, NY 12590 c. Po icy effective period: 03 13/11 to 03/13/12 /r~~~ MAR 1 1 2011 ~' 1~ '~ ~ 3d. T e Proprietor, Partners or Executive Officers are: ~ ~ ' ~-.~~ ~ ,~~ `' T~~/1~1 (~~ ~, P®T f~ ~ ~ ~ ~ ncluded. (Only check box if all partners/officers . ~ a T®~N CLER ~ d) 11 excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box " 3" insures the business referenced above in box "1 a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also note the above certtficate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, tltis Certificate is valid for a one year after this form is approved by the ittsurat:ce carrier or its licensed agent, or utttil the policy expiration date listed itz box "3c'; wliicl:ever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Karen A. Peters, CPCU Approved by: Title (Print name of authorized representative or licensed agent of insurance carrier) ~~~~~~~'''~ 03/08/11 (Signature) (Date) Assistant Vice President Telephone Number of authorized representative or licensed agent of insurance carrier: 518-244-4298 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2 authorized to issue it. C-105.2 (9-07) Insurance brokers are NOT www.wcb.state.ny.us NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1379 524-0 DATE 3/03/2011 CERTIFICATE NUMBER 215-550 :~:~:~~~€2iQE3:~CC3~R~b'SY>THI~.'•~~€t71~:~Ga;Tf~.'•:~:~':~:=:~:~:~: :::<:~::::1:~:~:~X::1~~~r6~::~'~:~:~:1:fob:J:~~r~t:~>:~':~:~:~:~:~:::~::: POLICYHOLDER DUTCHESS FIRE PROTECTION PO BOX 408 WAPPINGER FALLS INC NY 12590 CERTIFICATE HOLDER THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1379 524-0 UNTIL 11/01/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 11/01/2011 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 5 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 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 NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. MAR p 9 2C1 TOWN 0~= ~,~~J~1:~='~TNGER T®WiV CLERK AND CONFERS NO RIGHTS CERTIFICATE DOES NOT TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~~ ~~-~ . THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 253 rGRTn~_~i~nn~ ,~ PHILADELPHIA INDEMNITY INSURANCE COMPANY ONE BALA PLAZA SUITE 100 BALA CYNWYD PA 19004 ~~ Toff" ~F°2 ~O~~O ~Tn, ~.o , BIo.. ~ NOTICE OF CANCELLATION OF INSURANCE ~'/~j ~'.q~, ~~ A Named Ensured & Mailing Address: WOODHILL GREEN CONDOMINIUM ASSOCIAT 1668 ROUTE 9 STE 1 WAPPINGERS FALLS NY 12590 ~~ ~~~ ~~~ ~ ~ Producer: 0023404 DONN GERELLI ASSOCIATES INSURANCE AGENCY, INC 1 CROTON POINT AVE. CROTON-ON-HUDSON NY 10520 Reference: N/A Policy No.: PHPK646683 Type of Policy: PACKAGE INCLUDING AUTO Date of Cancellation: 03/16/2011; 12:01 A.M. Local Time at the mailing address of the Named Insured. We are cancelling this policy. Your insurance will cease on the Date of Cancellation shown above. The reason for cancellation is NONPAYMENT OF PREMIUM $15,643.85 This action is pursuant to New York Insurance Law, Section 3426, Subsection (c)(1)(A) regarding nonpayment of premium. The amount of premium overdue is: $15,643.85 Cancellation may be avoided if the overdue amount of premium is paid within 15 days of the mailing date of this notice. The first named insured or his/her authorized agent/broker may request in writing loss information with respect to this policy and previous policies we have written for you. We will provide this information within 10 days from the date we receive your request. PROOF OF FINANCIAL SECURITY IS REQUIRED TO BE MAINTAINED CONTINUOUSLY THROUGHOUT THE REGISTRATION PERIOD. IF YOU DO NOT KEEP YOUR INSURANCE IN FORCE DURING THE ENTIRE REGISTRATION PERIOD, YOUR REGISTRATION WILL BE SUBJECT TO SUSPENSION. IF YOUR VEHICLE IS STILL UNINSURED AFTER 90 DAYS, YOUR DRIVER'S LICENSE WILL BE SUSPENDED. TO AVOID THESE PENALTIES YOU MUST SURRENDER YOUR PLEASE READ THE NEXT PAGE FOR MORE INFORMATION Other Party of Interest TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 FORM# CC9697307003060780100411NY82010 ODEN 3.0.70.12a Copy for Other Interests Date Mailed: 25~th_ `da_y o~fFe~b~rula~ry~, 2011 ROSALIND M. JONES NYCC36NONPMNT 02252011 MYNY Page 1 of 3 PHILADELPHIA INDEMNITY INSURANCE COMPANY vim`^~ NOTICE OF CANCELLATION OF INSURANC ~, ~" //,,,, ~ Named Insured: WOODHILL GREEN CONDOMINIUM ASSOCIAT Policy Number: PHPK646683 v~/G ~~ .~,., n 2„ REGISTRATION CERTIFICATE AND PLATES ~ `~'' BY LAW YOUR '~ ~~~r~c YOUR INSURANCE EXPIRES. INSURANCE CARRIER IS REQUIRED TO REPORT ~ ~•~ SPECIFIC TERMINATION INFORMATION TO THE COMMISSIONER OF MOTOR VEHICLES. IF YOU HAVE A LAPSE IN INSURANCE COVERAGE OF 90 DAYS OR LESS, THE LAW PERMITS YOU TO AVOID A SUSPENSION OF YOUR REGISTRATION BY THE PAYMENT OF A CIVIL PENALTY FOR EACH DAY OR ANY PORTION THEREOF UP TO 90 DAYS FOR WHICH YOUR INSURANCE COVERAGE WAS NOT IN EFFECT. THIS CIVIL PENALTY OPTION APPLIES ONLY ONCE DURING ANY 36 MONTH PERIOD. THE CIVIL PENALTIES ARE: 1 TO 30 DAY LAPSE - $8 PER EACH DAY OF LAPSE 31 TO 60 DAY LAPSE - $240 PLUS $10 PER DAY FOR DAYS 31 TO 60 61 TO 90 DAY LAPSE - $540 PLUS $12 PER DAY FOR DAYS 61 TO 90 This policy provides auto liability coverage. You should contact your agent or any agent concerning your possible eligibility for replacement coverage through another insurer or the New York Automobile Insurance Plan. Excess premium (if not tendered) will be refunded on demand. This policy provides fire and extended coverage insurance on your property. You should contact your agent or any agent concerning coverage through another insurer, or your possible eligibility for coverage through the New York Property Insurance Underwriting Association, 100 William Street, 4th Floor, New York, NY 10038. Telephone: (800) 522-3372. Or, you may contact your agent or this insurance company at: Philadelphia Insurance Companies Brian O'Reilly 1009 Lenox Drive, Suite 107 Lawrenceville, NJ 08648 866-586-6122 212-208-9700 (Assigned Risk) PLEASE READ THE NEXT PAGE FOR MORE INFORMATION FORM# CC9697307003060780100411NY82010 ODEN 3.0.10.12a Copy for Other Interests NYCC36NONPMNT 02252011 MYNY Page 2 of 3 PHILADELPHIA INDEMNITY INSURANCE COMPANY NOTICE OF CANCELLATION OF INSURANCE Named Insured: WOODHILL GREEN CONDOMINIUM ASSOCIAT Policy Number: PHPK646683 Your interest in this policy as an "insured" or other party of interest is being cancelled effective 03/16/2011; 12:01 A.M. Local Time at the mailing address of the named insured. NYCC36NONPMNT FORM# CC9697307003060780100411NY82010 02252011MYNY ODEN 3.0.10.12a Copy for Other Interests Page 3 of 3 Technology Insurance Company 5800 Lombardo Center Cleveland OH 44131-2550 CERTIFICATE HOLDER NOTICE NEW YORK WORKERS COMPENSATION INSURANCE COVERAGE Certificate Holder: Town of Wappinger 20 Middlebush Road Wappinger Falls, NY 12590 Insured: Commercial Contracting Company, Inc. Policy Number: TWC3267826 Policy Period: 12/31/2010 to 3/10/2011 12:01 a.m. at the insured's mailing address Date of Notice: 2/24/2011 Notice Type: Cancellation Effective Date of Cancellation: 3/10/2011 12:01 a.m. at the insured's mailing address Endorsement No.: 3 Reason: Prem Due 3404.00 As a Certificate Holder on the above policy, you are hereby notified that in accordance with the terms and conditions of this policy, Workers' Compensation Insurance will cease on the date shown for the above named insured. If you have any questions regarding this notice, please contact the insured listed above. By: Authorized Representative ~~ ~`~~ Technology Insurance Company A member of the AmTrust Financial Group ' ul I ~ (~ (~ ~ ~~ D An AmTrust Financial Company A.M. Best Rating: A- ll~ll L~ `~~' I~ MAR 0 2 2011 TOWN tar= `~1iAPPINGER TOWN CLERK Rochdale Insurance Company 5800 Lombardo Center Cleveland OH 44131-2550 CERTIFICATE HOLDER NOTICE NEW YORK WORKERS COMPENSATION INSURANCE COVERAGE Certificate Holder: Town of Wappingers 20 Middlebush Rd Wappingers Falls NY 12590 Insured: O'Shea Electrical Contractors, Inc. Policy Number: RWC3221097 Policy Period: 11/1/2010 to 3/10/2011 12:01 a.m. at the insured's mailing address Date of Notice: 2/24/2011 Notice Type: Cancellation Effective Date of Cancellation: 3/10/2011 12:01 a.m. at the insured's mailing address Endorsement No.: 2 Reason: Prem Due 494.00 As a Certificate Holder on the above policy, you are hereby notified that in accordance with the terms and conditions of this policy, Workers' Compensation Insurance will cease on the date shown for the above named insured. If you have any questions regarding this notice, please contact the insured listed above. ,• Rochdale Insurance Company A member of the AmTiust Financial Group An AmTrust Financial Company A.M. Best Rating: A- By: Authorized Representative ~ ~~ GEC C~~~~ICD MAR 0 2 2011 TOWN OF WAPPINGER TOWN CLERK Rochdale Insurance Company 5800 Lombardo Center Cleveland OH 44131-2550 CERTIFICATE HOLDER NOTICE NEW YORK WORKERS COMPENSATION INSURANCE COVERAGE Certificate Holder: Town of Wappingers 20 Middlebush Rd Wappingers Falls NY 12590 Insured: O'Shea Electrical Contractors, Inc. Policy Number: RWC3221097 Policy Period: 11/1/2010 to 11/1/2011 12:01 a.m. at the insured's mailing address Date of Notice: 2/28/2011 Notice Type: Reinstatement Endorsement No.: 2 Reason: Payment received As a Certificate Holder on the above policy, you are hereby notified that the NOTICE OF CANCELLATION effective 3/10/2011 is superseded. Coverage has been reinstated without lapse for the policy period noted above. If you have any questions regarding this notice, please contact the insured. Rochdale Insurance Company AmemberoftheAmTrustFinancialGroup f.r: r~,rr';usi',•~a;i_~ia[ Gora;~any' A.M. Best Rating: A- T'ar~~/,4,. Authorized Re res ative ' MAR 0 7 2011 TOWN ~}~ ~~,GppINGER -- ~~~ ~.LERK NEW YORK STAT~~I1E INSURANCE FUND 1 WATERVLIET AVENUE ~518)54~7~6400ANY, NEW YORK 12206-1649 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ~: ~:.:.:. PC~€ti~Ei:.EC31C~R~D:. $Y1~Hi~~~f{'~IF:FC~:~~.:.:.:;:;>:.:.>:.: POLICYHOLDER BRYAN MURPHY CONSTRUCTION INC 24 DOWNEY AVE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1482 281-1 DATE 3/01/2011 CERTIFICATE NUMBER 714-812 CERTIFICATE HOLDER TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1482 281-1 UNTIL 6/07/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 6/07/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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 PO ~~~~~~~~ .,, r+.~. ~ MAR 07 2011 '- ' ~ ; . ~ ~ TOV`~~TV 0= ~~~~t'IiVGER TO ~~~1 ~'! ~:~ ~~ -.~.. ._' ... _.... ~. E THE STATE INSURANCE FUND ~~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 1113 CERT02-2/2001 .r~~ E ~ , ' New York State Insurance Fund " F"~; Worke~•s' Conzpe~zsatimz & Disability Benefits Specialists Since ]914 '°° "-' 1 WATERVLIET AVENUE ALBANY, NEW YORK 12206-1649 Phone: (518) 437-8976 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^ ^ ^ ^ ^ ^ 204260818 ABLE MIKE ELECTRIC CORP 17 LAKE ROAD HOPEWELL JUNCTION NY 12533 POLICYHOLDER i CERTIFICATE HOLDER ABLE MIKE ELECTRIC CORP TOWN OF WAPPINGER 17 LAKE ROAD 20 MIDDLEBUSH RD HOPEWELL JUNCTION NY 12533 ~ WAPPINGER FALLS NY 12590 i POLICY NUMBER !~ CERTIFICATE NUMBER I PERIOD COVERED BY THIS CERTIFICATE ' 3/ D 01E A 2017 800-0 443148 i 03/0312011 TO 03/03/2012 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2017 800-0 UNTIL 03103/2012, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OUTS DEIOOF NEWHYORK,TTO THEEPO IOCYHOLDER STREGULARICNEWDYORKOSTATE D MPLOYEES ONLY. TO OPERATIONS IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 03/03/2012 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 POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. MICHAEL S PALM, PRESIDENT SOLE OFFICER AND OWNER OF ABLE MIKE ELECTRIC CORP THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE D ES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. D ~~~~~~~ MAR ~ 7 2p?l T~ WC~ ~~ t~1f ;. ~~~ A,~pI~GER - ~~~~~ ~L~~K NEW YORK STATE INSURANCE FUND ~y~~~ ~~ ~ a~L.~r-+s~ U DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https:llwww.nysif.com/cerUcertval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 874130515 U-26.3 NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK. DR, STE~9~4~ 701T212QAIN5, NEW YORK 10604-3814 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 ~: ~:.:.:.i?~ic~iE3:.EC~t~~~l~:.8~l:.mWi~:.C~F~'11=iGR'{~ ::.:::.:::.:.:.:.:.: POLICYHOLDER EU-TE DESIGN LLC D/B/A EURO TECH CONSTRUCTION 181 BOYD ST MONTGOMERY NY 12549 POLICY NUMBER +W 1329 868-2 DATE 2/17/2011 CERTIFICATE NUMBER 287-068 CERTIFICATE HOLDER TOWN OF WAPPINGER ZO MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/09/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 555 ~~ ~_: G°~~C~~~MC D ~- FEB2220i1 TOWN OF WAPPINGER TOWN CLERK THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE~9~4f 701T212QAIN5, NEW YORK 10604-3814 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 .'•:.:.:.~~iic~iE3:.6C3.rl~~~l?:. $Y: ~mWi~:.E~t~1~I~:FGai ::.:::::.:.:.:.::: POLICYHOLDER EU-TE DESIGN LLC D/B/A EURO TECH CONSTRUCTION 181 BOYD ST MONTGOMERY NY 12549 POLICY NUMBER +W 1329 868-2 DATE 2/17/2011 CERTIFICATE NUMBER 305-010 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/09/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE iTPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. k V~ CANCELLATION U-26.3 \I~V ~ ~~ ^. r Tp u~2~011 T N aF ~'A ~ a ~~s~ ~C~ I LAGER ~k THE STATE INSU ~ FUND DIRECTOR, INSURANCE FUND UNDERWRITING $53 STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE ~518~54~7~6400ANY, NEW YORK 12206-1649 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :>::`:: PC~€i1f1E3:: EC31t~r~E[?::f3Y::?WIC::G~t~?I~:~CA7~:::::'::::::::::: ~: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1465 188-9 DATE 2/18/2011 CERTIFICATE NUMBER 044-914 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/10/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. t CANCELLATION U-26.3 203 FEB 2 4 2011 TOWN C7 a= Vy~PPINGER TOVIIN CLERK ,, THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :::::::A~i1<1E3.'•CC31/~R~d:~f3`~: ~ tWl~::~~€~~IF:1GA7f :::::::::::::::: ~: ~: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1465 188-9 DATE 2/18/2011 CERTIFICATE NUMBER 146-040 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/10/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~D CANCELLATION U-26.3 >~ ~.~ FEB 2 4 2011 ~'p V~~ i/U~ ppINGER ~L~RK THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING 195 cTnr.nni-~i~nn i NEW YORK STAT~~I1E INSURANCE FUND 1 WATERVLIET AVENUE ~518)54037~6400ANY, NEW YORK 12206-1649 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 :.>A~€tiQaCOU~R~b:.BY:.:CWI~:.srC~:1~IF:EG~4ti::.:.:.: ~:~: ~:.::: ~: ::::::::::¢.;':oa.l ~~a9:::~'~::::::~:f:~~{;~l~x;t ::::::::::::::::::::::: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1465 188-9 DATE 2/18/2011 CERTIFICATE NUMBER 997-535 CERTIFICATE HOLDER - TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/10/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE. PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CE IFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~.~.,, ~~0~ D ~D CANCELLATION U-26.3 FEE 2 4 2011 Tp '~~'' ~"~ r ~ p~ V ~~ lip ~~~w~~ .~ ~~~ ~ , e.._~ L,~r~,~ ~~~RNGFR ~, K THE STATE INSU~(RANCE FUND c~ DIRECTOR, INSURANCE FUND UNDERWRITING 341 ~Tnrani-~i~nn i NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE ~XTE~TSION, ALBANY, NEW YORK 12206-1649 51811 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 ~:~:: R~21Qb:~EC31l~i~Et~:~~Y>?WIl;:~~~f~t1~:EG;47~~:~:~:~:~:~::~: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1465 188-9 DATE 2/18/2011 CERTIFICATE NUMBER 347-553 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY125900324 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/10/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 ~j ~D ..~ _..:~ ~ _~ Tp FEB 2 4 20.1 ~ ,rQ Ur ~v~`~1~p~~GER THE STATE INSURANCE FU ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 351 STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 :~:~:~A~~€iiQd:~C05t~R~D:~$YtWIS>~E=€~7'IF::1G;;4tf~:~:~:~:~:~>:~:~: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1465 188-9 DATE 2/18/2011 CERTIFICATE NUMBER 758-168 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/10/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. v ~`"_ L '' (( "~~~~D CANCELLATION U-26.3 FEE 2 4 2011 Tp~~p~~ L~Rk- THE STATE INSU~(RANCE FUND _ ~} ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 357 cTnr n ni_ ~ i~ nn ~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE ~XTENSION, ALBANY, NEW YORK 12206-1649 518)) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :~`:~P~€#iQd:~EC~1l~RECi:~B~<tWl~:~ir~E2:~IF:FGEiT~~>:~:~:~:~: ~:~:~:~: POLICYHOLDER BRYAN MURPHY CONSTRUCTION INC 24 DOWNEY AVE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1482 281-1 DATE 2/22/2011 CERTIFICATE NUMBER 668-155 CERTIFICATE HOLDER TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/14/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. ~__ - 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. r°.~~~0~~~~ FEB 2 5 20'1 CANCELLATION U-26.3 TOWN Or WF~PPINGER TOWN CLERK THE STATE INSURANCE FUND d- DIRECTOR, INSURANCE FUND UNDERWRITING z~~~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICYHOLDER ~: ~ `::::7?~€i1f}E?::601t~l~frd: ~ 8~!:~ tWIS:~Ir~€~1'IF:~GA~~~>:~ ::::::::::::::: BRYAN MURPHY CONSTRUCTION INC 24 DOWNEY AVE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1482 281-1 DATE 2/22/2011 CERTIFICATE NUMBER 714-812 CERTIFICATE HOLDER TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/14/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. x ~7 G°~CC~[~~~~D FEB 2 5 2011 TOWN OF Vl%~PPINGER TOU1~~V CLERK CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING ~~7A NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~: ~':~i~C~€tiQEi>EOrt~R~Ei:~BY: ~ tHIlS:~~~f~~fiIF:~Ga:t~~::<~: ~':': ~: ~: POLICYHOLDER DUTCHESS FIRE PROTECTION INC PO BOX 408 WAPPINGER FALLS NY 12590 POLICY NUMBER +A 1379 524-0 DATE 2/22/2011 CERTIFICATE NUMBER 215-550 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/14/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. FEB 2 5 2011 TGwN OP W~i~'PINGER ,~-~,~~_ -~..~ TOWN CLERK _~ CANCELLATION U-26.3 THE STATE INSURANCE FUND DIRECTOR. INSURANCE FUND UNDERWRITING ~nn7 NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~- TOWN OF WAPPINGER ATTN: SHELLY 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~:~:~1?~€#fQE3:~C011~REC~:~fIY:~'CWI~:~Ir~E~7'I~:EGi>T~~>:~:~:~>:~:~:~:~: POLICYHOLDER J. D. PARRELLA ELECTRIC, INC. 299 WASHINGTON ST NEWBURGH NY 12550 POLICY NUMBER ~~G 2059 277-0 DATE 2/16/2011 CERTIFICATE NUMBER 465-768 CERTIFICATE HOLDER TOWN OF WAPPINGER ATTN: SHELLY 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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 POLIC ~~~``--- ~~//~~_ • t•1ll~V'~~V~~ ,, ~~ . ~'~-~.~ ~,~~ ~ FEB 1 8 2011 AWN UF~ WRPPINGER TOWN CLERK CANCELLATION U-26.3 THE STATE INSU/~RANCE FUND ~} ~ DIRECTOR, INSURANCE FUND UNDERWRITING 1283 NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (9145 701-2120 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE L~L~C~L~~ML~D ~~ TOWN OF WAPPINGERS FEB 16 2011 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 TD T® ~~ UVAppI1VGER .___ .~..lr_V_~ CLERK POLICY NUMBER -~W 1354 064-6 DATE 2/11/2011 CERTIFICATE NUMBER 380-543 ~::.'•::`1?C~€21Qd:: EC11t~R~b::SY::1`WI~' ~~E~fi't I~:~G;4*f ::::::::::::::`•::::: :: ~:::::::~:~:o~:l ~~~5:::~'~::::::~:f 081.~~7 ~ ::::::::::::::::::::::::::: POLICYHOLDER EDWARD SPADARO 264 SEMINARY RD CARMEL CONSTRUCTION INC NY 10512 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1354 064-6 UNTIL 5/08/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 5/08/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. ~~ ~~ THE STATE INSURANCE FUND ...~~~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 959 rwTn~_~»nn ~ NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (914j 701-2120 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +W 1484 087-0 DATE 2/08/2011 CERTIFICATE NUMBER 918-217 ~: ~>:.:. R~if)E3:. E01lEE3~[?:.BY:. tWi~~~f~tI~:FC~~~::.:.:.:.: ~::: ~: POLICYHOLDER RIA CONSTRUCTION INC P.O. BOX 7174 NEWBURGH NY 12550 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1484 087-0 UNTIL 5/22/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 5/22/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. ~[~C~[~~MCD FEB 1 1 2011 TOWN OF WAPPTNGER TOWN CLERK U-26.3 74~ CC: THE STATE INSURANCE FUND ...~~~~ DIRECTOR, INSURANCE FUND UNDERWRITING ~~orno_~~~nn~ NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (9145 701-2120 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS FALLS BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :~P~€t1f7t1:~CC/~rI~yFt~b:~$~Yy:~ tWl2/:g~~~f~7/1F-:ytC,.{A~'~~:~:~:~::~:~:: ~: ~: POLICYHOLDER RIA CONSTRUCTION INC P.O.-BOX 7174 NEWBURGH NY 12550 POLICY NUMBER +W 1484 087-0 DATE 2/08/2011 CERTIFICATE NUMBER 917-897 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1484 087-0 UNTIL 5/22/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 5/22/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. D ~, FEB Y 1 2011 `~ TOWN OF WAPP~N GER TQ~~ CLERK THE STATE INSURANCE FUND ~~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 7']Q ~r n-rnn ~ in nn n NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE WAPPINGER TOWN HALL 20 MIDDLEBUSH RD. WAPPINGER FALLS NY 12590 ::~>i?C~#iQEti:~CC3~R~D:~BY: tHi5:~~~E$~IF:FG;47~%:~:~:~:~::~:~:~: POLICYHOLDER LAMINATE FLOORING 8 AMERICANA BLVD EAST FISHKILL SYSTEMS INC NY 125336325 POLICY NUMBER ''`A 1186 618-3 DATE 2/08/2011 CERTIFICATE NUMBER 794-897 CERTIFICATE HOLDER WAPPINGER TOWN HALL 20 MIDDLEBUSH RD. WAPPINGER FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1186 618-3 UNTIL 9/19/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 EMFLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 9/19/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. G°~~C~~~MC~D FEB 11 2011 TOWN OE W'APPTNGER TO~NN CLERK ,,..T. - ----- _ _---- ----- --~-rr ' ~ ~,~ STATE INSURANCE FUND ~~~ ~~~~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING Q~z 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 sU~eet address only) 1b. Business Telephone Number of Insured STEPHAN KROELL DBA ENERGY ELECTRIC 845-282-2571 1c. NYS Unemployment Insurance Employer Registration 22 BROOKDALE ROAD Number of Insured MAHOPAC, NY 10541 1d. Federal Employer Identification Number of Insured or Social Security Number 204333583 2. Name and Address of the Entity requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity being listed as the Certificate Holder) The First Rehabilitation Life Insurance TOWN OF WAPPINGERS CompanyotAmerica 3b. Policy Number of Entity listed in box "1a": 20 MIDDLE BUSH ROAD DBL272164 WAPPINGERS FALLS, NY 12590 3c. Policy effective period: 03/9 010 to 03/18/2011 _. ~~ _e,,~~,. , 4. Policy covers: a. o Ali of the employer's employees eligible under the New York Disability Benefits aw ~~ (~~i7n „ b. ~ Only the following class or classes of the employer's employees: V`-' U V r~© SEP U ~ .2010 TpwN OF Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insu nce car~'~~~wAPPINGER '' above and that the named insured has NYS Disability Benefits insurance coverage as described above. V CLER Date Signed 8/31/2010 By K (Signature of insurance carrier's authorized representative or YS Lic ed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Title Sr. Vice President 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, NV 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 Disability Benefits insurance policies and NYS Licensed Insurance Agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (5-06) New York State Insurance Fund Workers' Compensation & Disability Benefits Specialists Since 1914 105 CORPORATE PARK DRIVE SUITE 200, WHITE PLAINS, NEW YORK 10604-3814 Phone: (914) 253-4871 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^ ^ ^ ^ ^ 204333583 STEPHAN KROELL DBA ENERGY ELECTRIC 22 BROOKDALE ROAD MAHOPAC NY 10541 -- _ POLICYHOLDER __ _ __ CERTIFICATE HOLDER STEPHAN KROELL M. ANTHONY ENTERPRISES, INC DBA ENERGY ELECTRIC PO BOX 859 22 BROOKDALE ROAD BREWSTER NY 10509 MAHOPAC NY 10541 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE W 1475 866-8 232326 03/20/2010 TO 03/20/2011 8/31/2010 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1475 866-8 UNTIL 03/20/2011, 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 03/20/2011 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 POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABIL-TY COMPANY. 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 FUNC 6~~ i~~ DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 259207824 i i_~F New York State Insurance Fund Workers' Compensation & Disability Benefits Specialists Since 1914 105 CORPORATE PARK DRIVE SUITE 200, WHITE PLAINS, NEW YORK 10604-3814 Phone: (914) 253871 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^ ^ ^ ^ ^ 204333583 STEPHAN KROELL DBA ENERGY ELECTRIC 22 BROOKDALE ROAD MAHOPAC NY 10541 POLICYHOLDER CERTIFICATE HOLDER STEPHAN KROELL TOWN OF WAPPINGERS DBA ENERGY ELECTRIC 20 MIDDLE BUSH ROAD 22 BROOKDALE ROAD WAPPINGERS FALLS NY 12590 MAHOPAC NY 10541 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE W 1475 866-8 ~ 232333 03/20/2010 TO 03/20/2011 8/31/2010 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1475 866-8 UNTIL 03/20/2011, 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 03/20/2011 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 POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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 FUNC ~Z~ i~~ DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.comlcert/certval,asp or by calling (888) 875-5790 VALIDATION NUMBER: 418816756 i i_~F STATE OF NE W YORK WORKERS' COMAENSATION BOARD CERTIFICATIC OF NYS WORKERS' COMPENSA'TfON INSURANCE COVERAGE i la. Legal Nante turd address of• Insured (lJse street address only) --^ - ] h. I3usincss 7 cleplume Number of insured ' Appolo Heating, Inc. 518-355-2296 Dba: J & J Sheet Metal Works lc. NYS I )nemplovment Insurance Employer ~ 868 Burdeck Street Rcgistralion Numher of insured ~ 4769657 7 Schenectady NY 12306 ~ Id. Additional Named Insureds: Appolo Heating Inc. dba dba J & J Heating 8 Cooling Wori: Location of htsured iUnly required i%c•averuge is speeifi'callr linrired In r•errnur lncntirnrs in Now Furk.Srcrte, i.e. n li'rrtp-7/p Policvl ~ Federal Tmployer Identification Numbe or Soeiai ucunty Number 204369056 2. Name and Address of the Entity Requesting Nroof of ~ 3n. Nsune rri Iu::urance Carrier Covern;;e (Entity Being Listed as the CcrtiGcatc Holder) i ~ Technology Insurance Compan Town of Wappingers Falls 20 Middlebush Road ~ 36. PolicJ~ Number of entit,~ listed in box " Wappingers Falls NY 12590 TWC32277$9 3c. Policy effective period: 12/31/2009 to 12/31/2010 3d• Tt¢c Pra:pr tarot, Partners or Executive Officers are: ~ X , inc lurle~i. (~~nl}• check hox if all partners%oi~cers included) ~_ _.. ~ nil excluded or• certain partners/officers excluded. This cenilies that rho insurance carrier indicated above in box "3" insures the business reli:reneed ~bnve in box "la" for workers' wmpensation under the Nr,v 1'ari; Slntc ~4'urAers~ Compensation Law. (7'o use this form. Nevv't'urk (T: t) crust tea Bated under item 3A on the INFORMAi'ION i'A(i6 ol'Ihe workers' compensation insurance policy). 1•he htsurancc C'urric:r or its licensed agent will send this Certificate of Insurance to the entity listed shove as the certiticatc holder in bnx "?". The hrsnronce ('nrr•ier will nlso nunji~ rha shove c•erlrficara /rnlder within 1 r7 dnv.,• /J' r, pnrirr r~ evurrahu! due ro nonpavntenl of premiums or within 3fJ dgvs ll~ rhea ore r•casrnrs nrher rhnn nonpgtrment of premiums tlrnt cancel thr m~'h i~ ~r alirninate rh.> insured from the coverage indicated nu this ('ertilicnla. ('Phase Helices Holy he sent ht~ regular mail.) Ulherw•isr, rhrs l'rrri/irate i.r valid for one year after this form is approved hr rite insurrurce cnrr•icr or iGs lic•cnsed agent, or vnlil the policy evpirnlion data lisrar/ iu hox ".ic", whichever is earlier. Please Note; Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named oa a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Worker,' Compensation Coacrape or other authorized proof that the business is comp)}•inK with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under prnalty of perjury, I certify that I am an authorized representative or licenser! anent of the insurance carrier referenced above aad that thr Homed insured has the coverage as depicted on this form. App,~c,,:,;d 1,~: Henry C. Sibley - (Print name of aulhnrized representative or licensed agent of ursurance carrier) ,q r,^ro•;,:c'. b~. .. .. .%%• X2.'3?/?009 (Sig»aturo) (l)aic) 'I itlc Underwriting Manager __ _. __._ . _ -.__--.___- _. .___ _. ___ __._....___._- E "Telephone Nun•.bcr <fcu!Ihnrir.cd representative or licensed r:gent of insurance carrrcr h0~ ~~~'~A-0173 --_ -` ~°`--~--~' ~~ ~` Please Noce: (hrly in.cnrnnce c•nrr•ico•.e and !heir lip,<n.erl agents are authorized ro i.asa,• !hr• r -/U,i.? forru. /nsurunca hrnkers nra NOT authorized !o iseue it C-105.2 (9-07) ~~` ~~ ~' -'~~ni't~l i^.1 FRr Workers' Compensation Law Section S7. Restriction on issue of permits and the entering into contracts unless compensation is secured. ]. The head of;t slate or municipal department, board, conunission or o(licc authori~cd or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof dul}~ subscribed by an insurance carrier is produced in a form satisfacton w the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein. ho~re~er, stall bc, ,;;;na~ruei a~ creating any liability on the part of such state or municipal department. board. commission or office to pity any cantpensaliatt to any such employee if so employed. 2. The head ~f a sli;le or municipal d~parim;;n;, uuard, commission or office aulltorizcd or rcduired by law to enter into any contract for or in connection ~~~ith any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any gciicral o,• special statute re~luiring or authorizing an} ..~;~h cur,tuicl. shall not enter into any such contract unless proof duly subscribed b) an insurance carrier is produced in a form satisi;cton to the chair. that compensation for all employees has been secured as provided by this chap~er. C-105.2 (9-t?7)Rc~.crsc ~~~~ ~~ ~~ ~p`~ ~n~t\IA~ C'.~ ~~r NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (914j 701-2120 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS FALLS BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :12~€#iod:~EC3.rl~R~b'f3Y>tWI~:~C~€tTI~:~Cat~ :~:~:~::~::~::~: POLICYHOLDER RIA CONSTRUCTION INC P.O. BOX 7174 NEWBURGH NY 12550 POLICY NUMBER +W 1484 087-0 DATE 2/07/2011 CERTIFICATE NUMBER 917-897 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/27/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. G°~~C~~~M~D FEB 1 ~ 2011 CANCELLATION U-26.3 T©WN CJF V1iAPPINGER TOWN ~L~RK THE STATE INSURANCE FUND ~,~.~~~~ DIRECTOR, INSURANCE FUND UNDERWRITING 1113 STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (9145 701-2120 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :~::~i?~€iiQEi:~E01l~REb:~~Y:~THIS:~C~€ITIF:FGi~Ti' ::~:~:~:~:~:~:~:: POLICYHOLDER RIA CONSTRUCTION INC P.O. BOX 7174 NEWBURGH NY 12550 POLICY NUMBER +W 1484 087-0 DATE 2/07/2011 CERTIFICATE NUMBER 918-217 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/27/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~~`~ ~LI V ~LVJ FEB 1 0 2r'1 TOUV~J ~.)«"- V~~~~PPINGER ~~:~~,~`~~°~ CLERK CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 1095 STDCAN-2/2001 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) lb. Business Telephone Number of Insured Tech-Mechanical FAB DC Inc. 845-473-1470 5 Parker Avenue lc. NYS Unemployment Insurance Employer Poughkeepsie, NY 12601 Registration Number of Insured Work Location of Insured (Only required if coverage isspecifrcally ld. Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e., a Wrap-Up or Social Security Number Policy) 320293306 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Guard Insurance Group 3b. Policy Number of entity listed in box "la" Town of Wappinger 20 Middlebush Road TEWC118556 Wappingers Falls, NY 12590 3c. Policy effective period 6/22/10 to 6/22/11 3d. The Proprietor, Partners or Executive Officers are Included. (Only check box if all partners/officers included) ^ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured m the coverage indicated on this Certificate, (These notices may be sent by regular mail.) Ot/:erwise ~f"eattrt5'D"u a ro oneye after t/:is form is approved by the insurance carrier or its licensed agent, or until the policy pirat~~r~ /:iclr ver is earlier. ~ II Please Note: Upon the cancellation of the workers' compensation policy indicated n this form i~~~~yyh~~'',, sry~-~s continues o be named on a permit, license or contract issued by a certificate holder, the business mu t provide th~f~rC~a't~'~~ Ider with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is compl in i tory coverage requirements of the New York Ctate Workers' Compensation Law. .1-OW~ (~~' ~('~~~~~~~ Under penalty of perjury, I certify that I am an authorized representative or license agent T~~~~a~~..~~K e erenced above and that the named insured has the coverage as depicted on this form. _..,. Approved by: Handwerger & Sons Inc. (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ,u•~ 7.-~.~.~ 2 / 7 / 2011 (Signature) (Date) Title: Unnderwriter Telephone Number of authorized representative or licensed agent of insurance carrier: 914-694-8700 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. /nsurance brokers are NOT authorized to issue it. C-105.2 (9-07) www.wcb.state.ny.us NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1448 745-8 DATE 2/04/2011 CERTIFICATE NUMBER 526-941 A~2ic~E3:~E0rl~R~D'~l!'TWiS>C~f~TI~:{C.;4f~ :::~:::::: :~:::: ;~~2r~~~a6~:~fr~:::~2tza~:~ar~f:~:~:::::::::::~: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/24/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~~~~~~~ FEB U 9 2~'1 CANCELLATION U-26.3 TOWN C:~~= l;rv~~~INGER TOWBV CLERK THE STATE INSUrRANCE FUND °~. d DIRECTOR, INSURANCE FUND UNDERWRITING 349 STDCAN- 2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ~:~:~:1?E€i1f1D:~C01f~RED: $Y: ?W15:~CE€i:TIF:IGA3P >:~:~:~: >::: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 POLICY NUMBER +A 1448 745-8 DATE 2/04/2011 CERTIFICATE NUMBER 368-565 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/24/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY ~Pf CANCELLATION U-26.3 ONLY AND CONFERS NO RIGHTS THIS CERTIFICATE DOES NOT G~C~C~!~[lM[~D FEB d 9 ZGi TOWN ~~= ~'~~.~F'IfVGER THE STATE INSURANCE FUND ~~~~~ DIRECTOR, INSURANCE FUND UNDERWRITING 343 STDCAN-2/2001 STATE OF NEW YORK WORKERS' COMPENSATION BOARD • CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name and address of Insured (Use street address only) M J S Electric Inc Attn: Marc Angot 176 Davis Rd Salt Point, NY 12578 lb. Business Telephone Number of Insured 845-635-1380 lc. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is spec~cally limited to certain locations in New York State, i.e a Wrap-Up Policy) New York 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder)- Town of Wappingers 20 Middlebush Rd. Wappingers Falls, NY 12590 Attn: Michelle 1 d. Federal Employer Identification Number of Insured or Social Security Number 141800724 3a. Name of Insurance Carrier Main St. America 36. Policy Number of entity listed in box "la": W1V13628 3c. Policy effective period: 02/08/11 to 02/08/12 3d. The Proprietor, Partners or Executive Officers are: ^ included. (Only check box if all partners/officers included) ®all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NI') must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment ofpremiums that cancel the policy or eliminate the insured from the coverage indicated on this Cert~cate. (77iese notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box "3c ", whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that cert~cate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Timothy E. Dean (Pnnt name of authonzed representative or licensed agent of insurance carver) Approved by: --"~~ L~ ~J 2/4/11 (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 845-454-0800 Please Note: Only insurance carriers and their licensed agents are authorized to issue t - ~n e NOT authorized to issue it. ~ ~ ~ ~ D C-105.2(9-07) cb.s e.ny.us ~v I FEB 0 7 20i1 TOWN CoF W~PPINGER a ~~ ~'®lti~(~ CLERK STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW I rHrc I 1.1 o De completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1a. Legal Name and Address of Insured (Use street address only) M.J.S. ELECTRIC INC 1b. Business Telephone Number of Insured 914-452-5977 176 DAVIS ROAD 1c. NYS Unemployment Insurance Employer Registration Number of Insured SALT POINT, NY 12578 861748 1d. Federal Employer Identification Number of Insured or Social Security Number 141800724 2. Name and Address of the Entity requesting Proof of Coverage (Entity being listed as the Certificate Holder) 3a. Name of Insurance Carrier Town of Wappingers The First Rehabilitation Life Insurance Company of America 20 Middlebush Rd 3b. Policy Number of Entity listed in box "ta": . DBL126505 Wappingers Falls, NY 12590 3c. Poficy effective period: Attn: Michelle 0 210 8/2 0 1 0 to 02/07/2012 4. Policy covers: a. ^/ All of the employer's employees eligible under the New York Disability Benefits Law b. ~ Only the following class or classes of the employer's employees: Under penalty of pe jury, I certify that I am an authorized representative or licensed agent of the insurance carcier referenced above and that the named insured has NYS Disabilit Benefits in y surance coverage as described above. 2/4/2011 D t Si C~~ a e gned By U'~ (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 I MPORTANT: If box "4s" 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 directl t th rtifi . y o. e ce cate holder. If box "4b" is checked, this certificate is NOT COMPLETE for the purposes of Section 220, Subd. a of the Disability Benefits Law. It must be mailed for completion to the Worker's Com ensation B d DB Pl p oar , ans 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 foal/ ofhis/her employees. Date Signed gy (Signature of NYS Worker's Compensation Board Employee) Telephone Number Title Please Note: Only insurance carriers licensed to write NYS Disability Benefits insurance po icies ar~l~ eASt~n~~s of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT uthorized to issue this form. DB-120.1 (5-06) FEB ~ 7 2011 TOWN OF WAi~PINGER TO!l1s~ CLERK NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8~8-997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS FALLS NY 12590 ::<~1?~€t10d:~6C3:V~R~D:~BY:~?HI~>it~f{'f1~:FC„R~~~:~:~:~:~>:~:~:~: POLICYHOLDER T W F CONTRACTING INC 211 CHESTNUT STREET PORT CHESTER NY 105733122 POLICY NUMBER +G 1243 153-2 DATE 2/03/2011 CERTIFICATE NUMBER 292-653 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1243 153-2 UNTIL 6/29/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 6/29/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. ~___.s_----~ ~~C ~~~ ~ D i. FEB p '1 2011 ~:' ~ ~ PINGER TpwN pF WAP T®~ ~ CLERK "- THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 3053 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~tSION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE WAPPINGER TOWN HALL 20 MIDDLEBUSH RD. WAPPINGER FALLS NY 12590 :~:~:~i2~1f~F3:~E01l~R~b:~SY?FIIS>~~ftTIF:{C.;4T~~:~:~:~:~:~:~:~: ~: POLICYHOLDER LAMINATE FLOORING SYSTEMS INC 8 AMERICANA BLVD EAST FISHKILL NY 125336325 POLICY NUMBER +A 1186 618-3 DATE 2/02/2011 CERTIFICATE NUMBER 794-897 CERTIFICATE HOLDER WAPPINGER TOWN HALL 20 MIDDLEBUSH RD. WAPPINGER FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/22/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 G~C~C~~OMC~D FEB 0 7 20?1 ~. ~~:n~ TOWN OF W~PPiNGER TOWN CLE~tK THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 333 c-rnr eni-~ inn ~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1482 281-1 DATE 2/02/2011 CERTIFICATE NUMBER 668-155 :~:~::pC-~tiQF3>C(31t~i~d:~~Y:~tWIi:~~~R:TIK:ECAt;' >:~:~ `':~.'•: POLICYHOLDER BRYAN MURPHY CONSTRUCTION INC 24 DOWNEY AVE WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1482 281-1 UNTIL 6/07/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 6/07/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE PrC ~, ONLY AND CONFERS NO RIGHTS THIS CERTIFICATE DOES NOT U Lt L'~ ~J ~ ~ ll L~ I. ~-J FEB 4 7 2011 TOWN OF WAPPINGER TO~~~N CLERK THE STATE INSURANCE FUND U-26.3 263 DIRECTOR, INSURANCE FUND UNDERWRITING CERT02-2/2001 NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~:~:~AC,€i1f1E3:~E0\l~RED:~f3Y: ?HIS:£~f~7~11<:EG;41'~ :~::~>:~:~:~:~: POLICYHOLDER T W F CONTRACTING INC 211 CHESTNUT STREET PORT CHESTER NY 105733122 CERTIFICATE HOLDER POLICY NUMBER +G 1243 153-2 DATE 2/03/2011 CERTIFICATE NUMBER 906-691 TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1243 153-2 UNTIL 6/29/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 6/29/2011 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. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE PO ONLY AND CONFERS NO RIGHTS THIS CERTIFICATE DOES NOT G3CC~~~~~C D °~ U-26.3 3017 FEB ~ 7 ~uil TOWN OF WApp~INGER TO'UV IV CLERK THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :~1?~Ei11~13:~G(31t~REd:~f3Y:~1'H15:~C~€~'+I~:EG;47f~:~:~: :~:~:~:~:~: POLICYHOLDER BRYAN MURPHY CONSTRUCTION INC 24 DOWNEY AVE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1482 281-1 DATE 2/02/2011 CERTIFICATE NUMBER 714-812 CERTIFICATE HOLDER THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1482 281-1 UNTIL 6/07/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 6/07/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONL NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THI AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY ;. , U-26.3 267 ~ ~ ~,u R 1 CGt1'r s i CE~~~i~~l~J FEBU72v~i TOWN OF Ul,,~~~~~JGER TO~~ ~~ER~ THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING CERT02-2/2001 PHILADELPHIA INDEMNITY INSURANCE COMPANY ONE BALA PLAZA SUITE 100 BALA CYNWYD PA 19004 REINSTATEMENT NOTICE Named Insured 8 Mailing Address: Producer: 0023404 WOODHILL GREEN CONDOMINIUM ASSOCIAT DONN GERELLI ASSOCIATES INSURANCE AGENCY, 1668 ROUTE 9 STE 1 INc 1 CROTON POINT AVE. WAPPINGERS FALLS NY 12590 CROTON-ON-HUDSON NY 10520 Policy No.: PHPK646683 Type of Policy: PACKAGE INCLUDING AUTO You recently received a notice advising this policy was being cancelled effective 01/31/2011 . This notice is to advise that the policy is being reinstated without lapse in coverage. r~ ~~~ _ ~~ Other Party of Interest TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 FORM# CT969897NY51995 ODEN 3.0.10.12a Copy for Other Interests G°~~C~f~O~I~D FEB 0 7 2Gi1 TOWN C)r UIr~APPINGER TOW~U CLERK Date Mailed: 2nd day of Febru~ry, 2011 ~ j-~ , EVER ARMSTEAD NYCT36 02022011SINY Page 1 of 1 NEW YORK STATE INSURANCE FUND 199 CHURCH STRiEB$8N997Y086,~ N.Y. 10007-1100 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS FALLS NY 12590 ~':~: PC~€21Q~:~COf~R~b:~~Y:~tHiS:~~~€~T1F:EC;4`~~~:~:~:~:~5:~<:~:~: POLICYHOLDER T W F CONTRACTING INC 211 CHESTNUT STREET PORT CHESTER NY 105733122 POLICY NUMBER +G 1243 153-2 DATE 2/03/2011 CERTIFICATE NUMBER 337-133 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0, 1243 153-2 UNTIL 6/29/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 6/29/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY AND CONFERS NO RIGHTS CERTIFICATE DOES NOT FEB U 7 ?G'1 ~.~_ j - ~, TC71~1/!V ~+F 1N~~~IN~ER ~"~ ~~~~!~ ~~E~K THE STATE INSURANCE FUND ~~~ ~~~~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 3047 C:FRT(1~-~/~17n 1 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~iSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ WAPPINGERS FALLS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 12590 POLICY NUMBER +A 1448 745-8 DATE 2/04/2011 CERTIFICATE NUMBER 174-621 ~:~:::::: A~€t1f1E3:: GC~5l~R~C5:~f3Y::1`Hlts::lr~€t1IF:~CA~'f :::::::::::::::::::: CERTIFICATE HOLDER WAPPINGERS FALLS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/24/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ,~ _ ~~ b ~~~~~M ~~ i FEB U 8 20,'1 T OwN OF WAPPING 7`O WN CLERK ER CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING ono NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ::~:~A~'~i1Qt3:~EC31l~REb:~8Y:~7Wl~:~~~f{~'IK:~CA'ff :~:~:~:~:~:~:~:~:~: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 POLICY NUMBER +A 1448 745-8 DATE 2/04/2011 CERTIFICATE NUMBER 175-923 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/24/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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 ~~ ~~ ~~D F ~~D F E ~ , Tows a °8 Zall l ~~~c~,kGFR ~ CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING ~„ Technology Insurance Company 5800 Lombardo Center Cleveland OH 44131-2550 CERTIFICATE HOLDER NOTICE NEW YORK WORKERS COMPENSATION INSURANCE COVERAGE Certificate Holder: Town of Wappinger 20 Middlebush Road Wappinger Falls, NY 12590 Insured: Commercial Contracting Company, Inc. Policy Number: TWC3267826 Policy Period: 12/31/2010 to 12/31/2011 12:01 a.m. at the insured's mailing address Date of Notice: 1/27/2011 Notice Type: Reinstatement Endorsement No.: 2 Reason: As a Certificate Holder on the above policy, you are hereby notified that the NOTICE OF CANCELLATION effective 1/27/2011 is superceded. Coverage has been reinstated without lapse for the policy period noted above. If you have any questions regarding this notice, please contact the insured. By: ""~7 e ~~ Authorized Representative ,• Technology Insurance Company A member of the AmTrust Financial Group An AmTrust Financial Company A. M. Best Rating: A- .- -. G°3~~~~c~-~~~ FEB u 4 ~_~1 TOWN Or WV~i7pINGE~ -~~ L~~~ CLERK NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~iSION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~::::::1?~€t1f~E5:: EOif~RED:~$~': ~ tWls: ~CE€i:TIF:~C<lt~~>::::::: ~::: ~: POLICYHOLDER MID HUDSON DEVELOPMENT CORP PO BOX 636 FISHKILL NY 12524 POLICY NUMBER +A 1317 868-6 DATE 1/24/2011 CERTIFICATE NUMBER 492-833 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1317 868-6 UNTIL 3/25/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 3/25/2011 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. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NGR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ' ~~~~OM ~,, . JAS 2 g 2011 TO ~ T ~ ~~ ~'~PjNG THE STATE INSURANCE FUND ~~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 1839 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~:~P~€tiQE3:~EC3~REd:~SY:~TWiS:~~~f{7'I~:EGQ7~~:~:~:~»: ;:~:~: POLICYHOLDER MID HUDSON DEVELOPMENT CORP PO BOX 636 FISHKILL NY 12524 POLICY NUMBER +A 1317 868-6 DATE 1/24/2011 CERTIFICATE NUMBER 642-157 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1317 868-6 UNTIL 3/25/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 3/25/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE, THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ON AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. TH S ~E ~ DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLI I/J~~~ ~~(j-~~_~ T~°~•'" ~IC=~ 1~ ~, r~.~.,-. .._ ~-~ ~~'~` JAN 2 8 2C;1 TpWN CLERNGER K THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 1849 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~:::::1?~€2iQF3::EC~1l~~~b:~$Y: tH15: CE€ITIE:{CAti= :~:<~:~::~:::::: POLICYHOLDER MID HUDSON DEVELOPMENT PO BOX 636 FISHKILL CORP NY 12524 POLICY NUMBER +A 1317 868-6 DATE 1/24/2011 CERTIFICATE NUMBER 399-798 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1317 868-6 UNTIL 3/25/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 3/25/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. r AND C NF 0 RIGHTS CER IFIC~~~~ SNOT ~~\,~, ~ ,~.~ ~~O ,. ro~N qN 2 8 Zp~l ~Rk R i THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 1875 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (914j 701-2120 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ BUILDING DEPARTMENT TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~: ~ `:::: P~€tfQF3::EC31l~REb:~f3Y:~ TW15: ~C~€~~I~:IG;4f:E:::::':::::::::.: POLICYHOLDER CROSSCUT CONSTRUCTION INC. PO BOX 522 PINE BUSH NY 12566 POLICY NUMBER +W 1479 395-4 DATE 1/24/2011 CERTIFICATE NUMBER 397-196 CERTIFICATE HOLDER BUILDING DEPARTMENT TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/13/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. y ~ ~ J C •~ ~ 1= C~ CANCELLATION U-26.3 T~~~~`~11 ~~;:; ~ ~ ^~ f ~ ~T~ ~. V ~ ~~ ~~.~.rn ~~il r~l ~'~~;~ `W~~~, THE STATE INSURANC FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING 1335 cTnr nni_~ inn ~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SION, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~- WAPPINGERS FALLS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~:::~: ~ P~€tfQF3CC3v~R~D81!::1'H15:; ~~E~:1"I~:FC;41'f :::::::::::::::::: ::::::::toy:~~:~~~~r~:::~~::::::;~:t:~3~~¢r~ ::::::::::::::::::::.:.: POLICYHOLDER MICHAEL J RODELL D/B/A ATLANTIC COAST CONSTRUCTION 6 MARLORVILLE RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1187 857-6 DATE 1/24/2011 CERTIFICATE NUMBER 511-325 CERTIFICATE HOLDER WAPPINGERS FALLS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/13/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~, ~~ .~ , ,_ ~~ ~ ~ ~: ~. CANCELLATION U-26.3 ~~~ ~,n ~. 'J T ~ ~~~ ~ ~ ~ ~ `"~~ C~~°~' ~ ~ THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 1235 NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (9145 701-2120 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 :~:.:.i?~€2iQF3:.E(31f~R~D:~$~!:~tW15: CEFt~IE::EGA7~~:~:~:~>:.:::::::: POLICYHOLDER EDWARD SPADARO CONSTRUCTION INC 264 SEMINARY RD CARMEL NY 10512 POLICY NUMBER +W 1354 064-6 DATE 1/24/2011 CERTIFICATE NUMBER 380-543 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/13/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE- PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ,.~ ~ _ ~,. f ~ ~~r>!~G'`~D ~ ..,~ TO~`,`~~ ~~ ~~~~.;~.~~j~IGER TC~V~~~i ~.L~~ CANCELLATION U-26.3 THE ST/A~TE INSURANCE FUND <^~~'~~~ ~~ DIRECTOR, INSURANCE FUND UNDERWRITING Qf 1 7 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 C G°~~C~[~~MC D JAfV 2~ 5 2011 TOWN OF WAPPINGER ~ ~`~ ~TC~1NN CLERK ir---,-_.._. _......_ . _.. _____ ~: ~:::::: A~€i1f1E9::CC~St~t#~b: ~SY:: tWl~:: ~~R:1"I~:~GA7'E:>::::::::'::: POLICYHOLDER BRYAN MURPHY CONSTRUCTION INC 24 DOWNEY AVE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1482 281-1 DATE 1/21/2011 CERTIFICATE NUMBER 668-155 CERTIFICATE HOLDER TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/10/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 THE STATE INSURANCE FUND C='~ ~o sL.~ ~ DIRECTOR, INSURANCE FUND UNDERWRITING -r ~ c NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE G3C~C~~~MCD ~~~ TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICYHOLDER JAN 2~5 2d'1 TOWN 0~ W1~~PINGER TOWN CLERK ~ ~ .~~ ~ ~ ~ ~:~::::: P~1f}E3::E01h=RED:~$~!:~tW15:~~~R:71~:ICa7E::::::::`::~:::::~: BRYAN MURPHY CONSTRUCTION INC 24 DOWNEY AVE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1482 281-1 DATE 1/21/2011 CERTIFICATE NUMBER 714-812 CERTIFICATE HOLDER TOWN OF WAPPINGER 20MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/10/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 THE STATE INSURANCE FUND _ ~~ /( DIRECTOR, INSURANCE FUND UNDERWRITING ~~~ NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~:~::p~€i1OE>:~EC3V~REt.~>SY:~tWlts:~sr~f~TIF:EC;4'~~~:~:~:~:~:~: ~:~:~:~: ::::::::::t:~:~:~:s~~~~~:::~'~::::::;~ta7'~:~~r~ ::::::::::::::::::::::::::: POLICYHOLDER T W F CONTRACTING INC 211 CHESTNUT STREET PORT CHESTER NY 105733122 CERTIFICATE HOLDER POLICY NUMBER +G 1243 153-2 DATE 1/18/2011 CERTIFICATE NUMBER 292-653 TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/07/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 ...~~ ~ x ~ JAS 24 ~v?1 . TOWN Or 'v!} TOWN CLERK ER THE STATE INSURAnNCE FUND ~4.~-~ DIRECTOR, INSURANCE FUND UNDERWRITING 7853 NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~:~::p~€i1Qf3:~EC111~I?ED:~f31!:~1'WIS:~C~€~1'I~:EGA~"~~:~:~:~:~:~:~:~:~:~: :~:~:~:~:~t:~:~:s:9.1;~~A6::~F~:~>:~~~f.f3~l~~~r~f:~:~:~:~>:~:~:~:~:~:~:~:~: POLICYHOLDER T W F CONTRACTING INC 211 CHESTNUT STREET PORT CHESTER NY 105733122 POLICY NUMBER +G 1243 153-2 DATE 1/18/2011 CERTIFICATE NUMBER 906-691 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/07/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 JA~1 2 4 ~~~i `.,,~~, TOWiV G~ uua~~iIVGER TaWN CLERK THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 7907 ~T~~,,,,~_-„-,,,,,, NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 518 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ~:~:~: R~€iiQE3:~E0~~~Ci:~f3Y'tHIS:~~~€2T:I~:tCaT~~:~:~:~>: >::~:~: POLICYHOLDER TIM BECK CONSTRUCTION 75 VASSAR RD POUGHKEEPSIE NY INC 12603 POLICY NUMBER +A 1251 722-3 DATE 1/20/2011 CERTIFICATE NUMBER 424-107 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1251 722-3 UNTIL 4/05/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/05/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS C DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. D ~~ ~~~o ~~~ ~~,, JAN 2 3 4 1. ~ 11 Tp Wig T®~~ c~ERK R THE STATE INSURANCE FUND ~~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 383 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1251 722-3 DATE 1/20/2011 CERTIFICATE NUMBER 464-833 >:~>i?~21QE3:~C011~R~D:~$Y:~~F115:~C~t~~I~:FGAt~~>:~:~:~>:~:~:~:~: POLICYHOLDER TIM BECK CONSTRUCTION 75 VASSAR RD POUGHKEEPSIE NY INC 12603 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1251 722-3 UNTIL 4/05/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' 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 4/05/2011 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. G°~[~C~~~~ICD ~ JAN 2 4 cJi1 TOWN OF WAPPINGER - TO tflf ~i CLERK THE STATE INSURANCE FUND ~~~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 381 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ':_:.:.1?C€2]Qd:.CC~1l~I~~b:~ flY TWiS:~~~€~11~:1ca~t~~: ~: ~: ~: ~:.:.:.:.:.: POLICYHOLDER TIM BECK CONSTRUCTION 75 VASSAR RD POUGHKEEPSIE NY INC 12603 POLICY NUMBER +A 1251 722-3 DATE 1/20/2011 CERTIFICATE NUMBER 123-404 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1251 722-3 UNTIL 4/05/2011 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 4/05/2011 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 5 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. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. 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. G°~CC~~~~ICD ~~ ~,~~ JAI'J 2 4 c ~ 11 ,TOWN OF VIIAPPINGER TOWN CLERK THE STATE INSURANCE FUND U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 325 CERT02-2/2001 Technology Insurance Company 5800 Lombardo Center Cleveland OH 44131-2550 CERTIFICATE HOLDER NOTICE NEW YORK WORKERS COMPENSATION INSURANCE COVERAGE Certificate Holder: Town of Wappinger 20 Middlebush Road Wappinger Falls, NY 12590 Insured: Commercial Contracting Company, Inc. Policy Number: TWC3267826_ Policy Period: 12/31/2010 to 1/27/2011 12:01 a.m. at the insured's mailing address Date of Notice: 1/13/2011 Notice Type: Cancellation Effective Date of Cancellation: 1/27/2011 12:01 a.m. at the insured's mailing address Endorsement No.: 1 Reason: Renewal Nonpay 3377.00 As a Certificate Holder on the above policy, you are hereby notified that in accordance with the terms and conditions of this policy, Workers' Compensation Insurance will cease on the date shown for the above named insured. If you have any questions regarding this notice, please contact the insured listed above. c ,~~ BY= Authorized Representative ,• Technology Insurance Company An AmTrust Financial Company A member of the AmTrust Financial Group A. M. BestRating.~ A- JAN 21 2011 TOwN OF WAPPINGER '~~ ~ `~ ~ Tp W N `°~ - ~. ~ ~ ~ ~~`~~ CLERK NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8~8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~: ~:.:~`R~i~t~:.E~.~R~[?:~$Y:.1~Wi~:~ C~Et1'IF:ECAT~?<:`•<:~:~: ~: ~:? POLICYHOLDER T W F CONTRACTING INC 211 CHESTNUT STREET PORT CHESTER NY 105733122 POLICY NUMBER +G 1243 153-2 DATE 1/18/2011 CERTIFICATE NUMBER 337-133 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/07/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~~~U U ~D ..:.~_ ~ JAN 2 Y 2011 >~:~.r~ ,' TOWN OF Wgpp TOVViV c~ERK ER THE STATE INSURANCE FUND CANCELLATION ~~ U-2C).3 DIRECTOR, INSURANCE FUND UNDERWRITING 7859 ~__,.... .. ...,.... NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICYHOLDER ~: ~>:.:. A~€#iQE3:. E ~:V~ RED: ~ 81!: ~ ?W I B: ~ C ~€~t1i=:FGatf ~: ~: ~: ~: ~:.:.:.:.:.: CERTIFICATE HOLDER TIM BECK CONSTRUCTION INC 75 VASSAR RD POUGHKEEPSIE NY 12603 POLICY NUMBER +A 1251 722-3 DATE 1/19/2011 CERTIFICATE NUMBER 123-404 TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 `~~ ~- G°~C C~~OM[~D JAN 21 2011 TOWN OF WAPPINGER TOWN CLERK THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 2Fi 7 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ~: ~::::::PC-~2iQE3:: EC31t~REd:~$~!>?WI5:~~~R'fi1~:EGA'f~~:: ~: ~:<~:~::::::: POLICYHOLDER TIM BECK CONSTRUCTION INC 75 VASSAR RD POUGHKEEPSIE NY 12603 POLICY NUMBER +A 1251 722-3 DATE 1/19/2011 CERTIFICATE NUMBER 464-833 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~-~ ~ ~ JA~4 21 2011 ~~ ~ TOWN O~ WAPPINGER ~ ~ RK TOW -~ OLE CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 811 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICYHOLDER ~:~:.>:.R~€3iQE3:. EC31l~I~~b:~~Y: ~ TWiS: ~C~E27`IF:~CA7'~~: ~: ~": ~: ~:~:<~: TIM BECK CONSTRUCTION INC 75 VASSAR RD POUGHKEEPSIE NY 12603 POLICY NUMBER +A 1251 722-3 DATE 1/19/2011 CERTIFICATE NUMBER 424-107 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/08/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. ~~.L~C~L~~ML~D (,~ ~~ ~ JA~121 2011 TOWN OF WAPPINGER TOWN CLERK CANCELLATION U-26.3 THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 813 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICYHOLDER ~: ~:.:.:.1?C-€~iQE:.CC3rt~R~r~:~$Y:~CHIS>~~f~:T1~:~C:aT~::.:.:.>:.>:.::: POLICY NUMBER +A 1317 868-6 DATE 1/10/2011 CERTIFICATE NUMBER 492-833 CERTIFICATE HOLDER MID HUDSON DEVELOPMENT CORP PO BOX 636 FISHKILL NY 12524 TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 1/30/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 ~~~~~~~~ f"~'~ { ~ JAN 1 3 2011 «~ TOWN Or~ WA~'PrNGER T®~~ CLERK THE STATE INSURANCE FUND i ,,~~~~~ DIRECTOR, INSURANCE FUND UNDERWRITING ~ni~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICYHOLDER >:.:.A~€tiOb:.EC75l~R~D:~f3Y: tHi5:~~~€~71K:FC.;47f ::.:.::.:.:::.: :::::::::~~z~~;~~0.8::f~::::>f~~~ar.f ::::::::::::::::::::::::::: POLICY NUMBER +A 1317 868-6 DATE 1/10/2011 CERTIFICATE NUMBER 399-798 CERTIFICATE HOLDER MID HUDSON DEVELOPMENT CORP PO BOX 636 FISHKILL NY 12524 TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 1/30/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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.I~-"'-""------.___e..__ CANCELLATION U-26.3 ~~~~~M~D ~~ JAN 1 3 2011 ~` TOWN ~7F 1N~PPINGER ~~WN CLERK ~t _.____.._ THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING ini~ STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE ~' la. Legal Name and Address of Insured (Use street address only) lb. Business Telephone Number of Insured (845)473-4177 Siegrist & Sons Construction, Inc. dba Siegrist & Sons Construction, Inc. lc. NYS Unemployment Insurance Employer Registration 6 Orchard Pl Number of Insured Poughkeepsie, NY 12601-1912 ld. Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured (Only required if coverage is specifically 260377397 limited to certain locations in New York State, i.e, a Wrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Continental Indemnity Co. Town of Wappinger 3b. Policy Number of entity listed in box "la": 20 Middlebush R ad '""r" 46-818207-01-02 W appinger Falls, Y 12~ ~ ~ (~ ~ (~ (J ~ D (~ \f 3c. Policy effective period: 09/13/10 ~ 09/13/11 ~.n3 JAN 1 3 Z~'1 re: Off ti E icers a xecu ve 3d. The Proptetor, Partners or l d d) ffi l / d d TOWN 0 F WA P PI N G E R e cers ac u o . (Only check box It sll partners e ^ inclu ~O W N CLERK ®all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box " 3" insures the business reterenceu above in uox ••><a•• for woricers• compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATIONAL PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send the Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box "3c'; whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Chris LaMantia (Print name of authorized representative or licenced agent of insurance carrier) Approved by: 01/10/2011 (Signature) (Date) Title: Authorized Representative Telephone Number of the authorized representative or -icensed agent of insurance carrier: (877)234424 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it C-105.2 (9-07) NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE FXTE~TSIGN, ALBANY, NEW YORK 12206-1649 (518) 437-6400 CANCELLATION OF CERTIFICATE ~AEtWORKERS' COMPENSATION INSURANCE ~~~~Ol~ TOWN OF WAPPINGER SAN 1 4 2C;~ 20 MIDDLEBUSH ROAD TQ WAPPINGERS FALLS NY 12590 ~.O QF V~1,gppjNG VI/iV cL~~K ER ~~1 A ~. ~:~:~PC-€2iQd:~E(31l~REd:~ $Y:~1'WIB:~~~f~?I~:EGRC~~:~:~:~:~:~>:~:~: POLICYHOLDER MID HUDSON DEVELOPMENT CORP PO BOX 636 FISHKILL NY 12524 POLICY NUMBER +A 1317 868-6 DATE 1/10/2011 CERTIFICATE NUMBER 642-157 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 1/30/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CANCELLATION U-26.3 THE STATE INSURANCE FUND d-~~ DIRECTOR, INSURANCE FUND UNDERWRITING ,.,~~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE ~XTE~I5ION, ALBANY, NEW YORK 12206-1649 (51811 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1447 622-0 DATE 1/06/2011 CERTIFICATE NUMBER 429-535 ~: ~:.:.:.i?~€iiOb:. GClV~REd:.iiY:~ tFlis:.C~Ft1'I~:{GA'tf;:.:.>:.:.:_:;: POLICYHOLDER RICHARD J DELUCA DBA Al REMODELING EXPERTS BY DELUCA HOMES 18 PETERS RD HOPEWELL JCT NY 12533 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 1/26/2011. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. 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. CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ` ~- ~,.~ ~- JAN 1 1 2011 TOWN OF WAPPINGER TOWN CLERK THE STATE INSURANCE FUND CANCELLATION U-26.3 ~~~- DIRECTOR, INSURANCE FUND UNDERWRITING 359 rrr~r n w~ ~ innn ~ STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE ia, Legal Name & Address of ]nsured (Use street address only) lb. Business Telephone Number of ]nsured Appolo Heating Inc. $45-464-4551 DBA: J & J Sheet Metal Works 1c. NYS Unemployment Insurance Employer 868 Burdeek Street Registration Number of Insured Schenectady, NY 12306 4769657 7 WorkLocatlonof[nsured(Onlyre7ulredlfcoveragefsspee~cally td. FederalEmpioyerldentiticationNumberorlnsured limited to certain locations fn New York State, i.e., a Wrap-Up or Social SeCUrlty Number Pollc~) 204369056 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier . Coverage (Entity 9eing Listed as the Certificate Holder) N@W f'f8n'1pShlr@ lnS CO. Town of Wappinger f=alls 36. Policy Number of entity listed in box "la" 20 Middlebush Rd WC017089525 Wappingers Falls NY 12590 3c. Policy effective period 12/31 /2010 to 1 2131120 1 1 3d. The Proprietor, Partners or Executive Officers are ^/ included. (Only check box If ell partaere/oltlcerslncluded) ^ all excluded or certain partners/o[ticers excluded. This certifies that the insurance carrier indicated above in box " 3" insures the business referenced above in box "la" for workers' compensation under the !Jew York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under 1 m 3 on the INFORMATION FACE of the workers' compensation insurance policy). The insurance Carrier or Its licensed agentwill send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2", The insurance Carrier will also nat(fy the above cert~cate holderwfthin 10 days !Fa policy is canceled due to nonpayment of premiums or within 30 days !F There are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mall) Otherwise, this Cert(Jicate is valid jot one year yfer this form is approved by flee insurance canter or its licensed agent, or until the policy expfratian date /Lsled in box "3c", ~~{{~((gyer !s earliar. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be Warned on a permit, license or contract issued try a certificate holder, the busineaa must provide that certificate holder with a new Certlticafe of Workers' Compensation Coverage or other autborized proof that the busineaa is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, [ certlfq that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named Ensured has t~e coverage as depicted on this form. Approved by: ~ ~'° . , (Print name of such Yizad 4fepresen ' E Ci'lice ad agent of insurance carrier) ` "~'4t'~ ~e Approved by: ~":="_.-~ _ \ fJC.. . ~.,~~:~~. _...~...`:' _ ' ~`S ~~I ~' s~ (Signature) (pate) Title: G~f1,`C-'~- U1~~111~u"'T~''1C1 ~C~S~ Telephone Number of authorized representative or licensed agent of insurance carrier: aG~~C earl ~ 3~ b Please Note: Only insurance carriers and their licensed agents are authorf~ed to fsstre -105.2. insurance brokers are NOT authorized to Issue it. D C-105.2 (4-07) L~ ~~~.us JAN 0 7 2011 TD~N ®F !~'HppINGER TOwn~ ,~- r_... STATE OF NEW YORK WORKERS' COMPENSATION BOARA CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Lags) Name & Address of Insured (Use street address only) lb. Business Telephone Number of Insured Appolo Heating Inc. 845-464-4551 DBA: J & J Sheet Metal Works Ic. NYS Unemployment Insurance Employer 868 Burdeek Street Registration Number of Insured Schenectady, NY 12306 4769657 7 Work Location of Insured {Dnlyregulred ljcoveragetsspecTJleally Id. Federal Employer Identification Number of Insured limited to certain locnu'ons to New York State, te., a Wrap-Up or Social Security Number Policy) 204369056 2. Name and Address of the Entity Requesting Proof of 3a. Name of insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) New Hampshire Ins Ca. Town of Wappinger 3b. Polley Number of entity listed in box "la" 20 Middlebush Rd WC017089525 Wappingers Falls NY 12590 3c. Foiicy effective period 12131/2010 to 12/31/2011 3d. The Proprietor, Partners or Executive Officers are © included. (Daly check box flan partneratotlicera tnefuded) all excluded or certain partners/ofYlcers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. ('I'o use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy), The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier tvIII also notjfy the above cart jncate holder within 10 days IPapolicyis canceled due to nonpayment of premiumss or within 3O days /F there are reasons other than nonpayment of premiums that cancel the policy or eltmtnate the Insured from the coverage Indicated on this Cert~cate. (These notices may be sent by regular mail.) Otherwise, Pubs Certtllcate Js va!!d jar one year aJterthls form is approved by the insurance carrier or Its licensed agent, or unll! the policy explratton date listed to bax "3c", fyhlehever ~s,~atller. Please Note: Upon the cancellatioa of the workers' compensation policy indicated on this form, !f the business continues to be named on a permit,llcenae or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business !s complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that t am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has t coverage as dopicted oa this form. Approved by: •~,rl •e'~` ~ r (Print name of aut-horyr~ead r sentatiue• r+lice ed agent of insurance carrier) ;• Approved by: ~~' '~f` y.c~-rJL~,_ ~ Cii.. -.z~.~.~*ae._._ . ,,~'`( ~~~` , (Signature) (Date) ~ '~ _ 1 t ` (' C r Title: Carle-~- ~jf ~,~3(~:a,~Tl(1 ~'~1C~/I.>r Telephone Number of authorized representative or Licensed agent of insurance carrier: ~.~~~ b~ Please Note: Only insurance carriers and their licensed agents are authorl~ed to issue Form -LOS. /! ~~ authori=ed to issue it. c-)os.2 (9.0~) J>4~ad~.st~t~.~.us TOWN OF WgppjNGER TOWN CLERK STATE OF NEW YORK WORKERS' 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 I a. Legal Name and Address of Insured (Use street address only) 1 b. Business Telephone Number of Insured LORI M. WAREING 845-226-7193 109 STAGECOACH PASS ic. NYS Unemployment Insurance Employer STORMVILLE, NY 12582 Registration Number of Insured 2322171 ld. Federal Employer Identification Number of Insured or Social Security Number DBA : LORJEN ELECTRIC L S 141804203 2. Name and Address of the ntity 3a. Name of Insurance Carrier (Entity Being Listed as the ertificate Holder) Zurich American Insurance Company Town of Wappinger JAN 0 3 58 South Service Road, Melville, NY 11747 20 Middlebush Road Z~~~ Wappingers Falls, NY 12~ 3b. Policy Number of entity listed in box "la": TO1NN OF WgppjNGER 1768140 - 001 K 3c. Policy effective period: - 1/1/2010 To 1/1/2011 4. Polic covers: ' a. ~X All of the employer's employees eligible under the New York Disability Benefits Law b. ~ Only the following class or classes of the employer's employees: Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYSlDisability Benefits insurance coverage as described above. Date Signed 12/1/2010 By /G~.,G*'"-/~`~~'~' (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (631) 845-2200 Title Operations Manager IMPORTANT: !f 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 purposes of Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed for completion to the Workers' Compensation Board, DB Plans Acceptance Unit, 20 Park Street, Albany, New York 12207. PART 2. To be com leted b NYS Workers' Com ensation Board Onl if box "4b" of Part 1 has been checked State Of New York Workers' Compensation Board According to information maintained by the NYS Workers' 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 Workers' Compensation Board Employee) Telephone Number Title Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.] (5-06) Additional Instructions for Form DB-120.1 By signing this form, the insurance carrier identified in box "3" on this form is certifying that it is insuring the business referenced in box "1 a" for disability benefits under the New York State Disability Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box " 2". This Certificate is valid for the earlier ojone year after this form is approved by the insurance carrier or its licensed agent, or tl:e policy expiration date listed in box " 3c ". Please Note: Upon the cancellation of the disability benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate ofNYS Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law. DISABILITY BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article, and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. DB-120.1 (5-06)