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2010 (2)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 r ~..~ t T°w~ OF vv,~ppZN~,E 7`O ~/~ C~~RK R :~:~:~p~EtiQE3:~Ed5l~R~ti:~$Y:~tWI~:~C~€~TI~iG~41'~~>:~:~:~:~:=:~:~:~: POLICYHOLDER PICCO CONSTRUCTION LLC 154 EAST BOSTON ROAD MAMARONECK NY 10543 POLICY NUMBER +Z 1363 272-4 DATE 12/27/2010 CERTIFICATE NUMBER 121-471 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 1/16/2011. 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. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRECTOR, INSURANCE FUND UNDERWRITING 14783 cTnr n ni_ ~ i~ nn ~ NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE f3F-~QBI~ERS' COMPENSATION INSURANCE ~_ y ~~ TOWN OF WAPPINGER j 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 DEC 0 3 20~ TOWS OF Vl/APPrNGER ~~~-~ ELK ~:~:::::: PC-~21QE~::E011~t~~CS'$Y::TWI~:: E~F~~I~:FC~4T~:::`> ::::::::::::: POLICYHOLDER NECKLES BUILDERS INC 47 WEST OLD FARMS ROAD HOPEWELL JUNCTION NY 12533 POLICY NUMBER +G 1316 863-8 DATE 12/27/2010 CERTIFICATE NUMBER 171-097 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 1/16/2011. 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. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~a J -'_ DIRECTOR, INSURANCE FUND UNDERWRITING 839 c-nrn~i_~i~nn~ NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (9145 701-2120 CERTIFICATE OF WORKERS' COMPENc ~ •rin~r =r;SURANCE ~~ TOWN OF WAPPINGERS DEC 2 9 210 20 MIDDLE BUSH RD WAPPINGERS FALLS NY 12590 TOV~N ~F WAPPRK E TOWN CLE~____. ~: ~ >: ~ 1?~€i1QE3: ~ E 0~l~~CS: ~ 81!: ~ t Fi 1 S 5 ~l€~~I ~:{C~47~ ~: ~: ~: ~: ~: ~: ::::::::::~~:o~~~~~r5:::~~:>:::5:fQ8~ar~:::> :::::::::::::::::::::: POLICYHOLDER EDWARD SPADARO CONSTRUCTION INC 264 SEMINARY RD CARMEL NY 10512 POLICY NUMBER +W 1354 064-6 DATE 12/24/2010 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 5/08/2011 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 IN~S(URANCE FUND _ d v~-~ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 41 OZ ..~r,T.,,, ., ,.,,,,, . 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 ~C~C~~OML~D TOWN OF WAPPINGER FALLS 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 ~~ ~. ~. } DEC 2 g 2010 POLICY NUMBER ''~W 1369 249-6 DATE 12/24/2010 CERTIFICATE NUMBER 900-821 TOWN OF WAPPINGER .-.. T~wN CLERK :~:~::p~€21f7E3:~EC31l~REb>8~!:~tHl>:~C~t1r1'I~:IG~k~'~~»:~:~:~:~:~:~:~: POLICYHOLDER JOHN FALVELLA INC 47 UNION SCHOOL RD MONTGOMERY NY 12549 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. 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 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 R41 CERT02-2/2001 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 FALLS 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 POLICY NUMBER +W 1369 249-6 DATE 12/17/2010 CERTIFICATE NUMBER 900-821 :~:~:~PC€21QE3:~EOSt~REd:~f;Y:~?WIi~:~lr~EtTI~:IG;47f~:~:~:~:~:~:~:~:~:~: ::~:~:~:~::fob:o3~~,~'~r9:~:~1~r#:~:~:~~~f~~l:~~r~:~:::~:~:~:~:~:~:~:~:~:~:~: POLICYHOLDER JOHN FALVELLA INC 47 UNION SCHOOL RD MONTGOMERY NY 12549 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 1/06/2011. 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 _ _ DEC 2 2 2010 TOWN OF WAPPI~NK ER TOWN CLE THE STATE INSURANCE FUND c~~ DIRECTOR, INSURANCE FUND UNDERWRITING 177 STDCAN-2/2001 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 MIDDLEBUSH ROAD WAPPINGERS FALLS FALLS NY 12590 ~:~:~> P~iOd.'•CO.rt~RE~:~f3Y: ~ tWi~.'•~~€~tI~:EG;47~~>:~:~:~:~:~:~:~>: POLICYHOLDER BLUE HAVEN POOLS NY INC 11 PADDOCK DRIVE - SUITE B CHESTER NY 10918 POLICY NUMBER +W 2082 626-9 DATE 12/20/2010 CERTIFICATE NUMBER 248-323 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. 2082 626-9 UNTIL 5/24/2011 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 5/24/2011 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 COVF,RAr:F AFF(IRT~F.n RY THF. PO .ICY. I~C~C~COMCD DEC 2 3 2010 TOWN OF WAPPINGER ~~~~ ; ,: TO~l~! LLERK ~ ~ THE STATE INSURANCE FUND ~~%.___ 7~e_ U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 2957 CERT02-2/2001 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 Storey Electric Inc. 845-677-8792 37 Oswego Road Pleasant Valley, NY 12569 lc. NYS Unemployment Insurance Employer Registration Number of Insured 0745165 ld. Federal Employer Identification Number of Insured Work Location of Insured (Only required if coverage /sspeciftca//y or Social Security Number limited to cerlrr/n locations in New York State, i.e., a Wrap-Up 223879242 Policy) 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Sentinel Insurance Co Town of Wappingers 3b. Policy Number of entity listed in box "la" 20 Middlebush Road 16WECPY6506 Wappingers Falls, NY 1 590 ~~~~~~ t7~D v 3c Policy effective period . D : 12/31/2010 to 12/31/2011 ~ . ;a,~ WAPPINGER 3d. The Proprietor, Partners or Executive Officers are ,wro TOWN OF CLERK TOWN ~~• ~ ~ included. (Only check box if all partners/officers included) X all excluded or certain artners/officers excluded :. ~ p . 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 notes the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiunts 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 Certifrcate. (These notices may be sent by regular marl.) Otherwise, t/tls Certificate is vn/ill for o~te year offer this form is approved by the /ns[rrnnce currier or its licensed agent, or until the policy erp/ration dote listed in bor "3c ", wlr/clrever 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: Approved by: -Joseph Pires, President - PF Northeast Brokerage Inc (Print name of authorized representative or licensed agent of insurance carrier) 12/22/ 10 ( ignah~re) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: _845 223-8107 P/ease Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT atrthor•ized 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 DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~:~: ~:~ P~€iiQE3: ~EC3rl~REl~: ~SY? tHiS:~ E~E~TIF:fC.A'~~~:.<>`.'•.'•':~`: POLICYHOLDER HOFFMAN HOMES & REMODELING SPECIALISTS INC 15 SACHSON PLACE WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1465 188-9 DATE 12/20/2010 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 1/09/2011. 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. G°~CC~C~~MI~D DEC' 2 7 2010 TOWN OF WAppINGER TOWN CLERK CANCELLATION U-26.3 1775 3 b THE STATE INSURANCE FUND ~~~ DIRECTOR, INSURANCE FUND UNDERWRITING STnraN-~i~nni 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 12/22/2010 CERTIFICATE NUMBER 380-543 :~:~:~A~€iiOt~:~EOV~RE[~:~SY:~tWIS:~C~€t~IF:tC.~T~~:~:~:~:~:~:~:~:~:~: 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 1/11/2011. 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. ~~~~~~~~ ~`~ ~ DEC 2 7 2010 TOWN OF WAPPINGER TOWN CLERK THE STATE INSURANCE FUND CANCELLATION U-26.3 DIRECTOR, INSURANCE FUND UNDERWRITING 2075 STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKELtS' COMPENSATION INSURANCE ~~~~~~ D TOWN OF WAPPINGER DEC ~.,5 2010 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 TOWN OF WAPPINGER T~wN CLERK __,~ :~:~.'•P~2ibE~:~E011~RED:~~Y:~isWIS>~~€ttIK:FC~~C~~:~:~:~:~:~:~:~:~': POLICYHOLDER RICHARD J DELUCA DBA Al REMODELING EXPERTS BY DELUCA HOMES 18 PETERS RD HOPEWELL JCT NY 12533 POLICY NUMBER +A 1447 622-0 DATE 12/10/2010 CERTIFICATE NUMBER 429-535 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. 1447 622-0 UNTIL 3/23/2011 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 3/23/2011 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. THE STATE INSURANCE FUND U-26.3 ~~ DIRE R, INSURANCE FUND UNDERWRITING 347 CERT02-2/2001 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) 1 b. Business Telephone Number of Insured Camo Pollution Control Inc 845-463-7310 Julie Cea 1610 Rt 376 lc. NYS Unemployment Insurance Employer Wappingers Falls, NY 12590 Registration Number of Insured 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 Policy) or Social Security Number 141514539 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Ilolder) Town of Wappinger 20 Middlebush Rd Wappingers Falls, NY 12590 --~~ 2~0 2010 i~OWN OF WAPPINGE TOWN CLERK 3a. Name of Insurance Carrier Selective Insurance Company of America 3b. Policy Number of entity listed in box °°la": Policy effective period: O1/O1/11 to 01/01/12 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 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 ofpremiums 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: Timothy E. Dean (Print name of authorized representative or licensed agent of insurance carver) Approved by: --`J~- L~ ~} '~~ff ~---- 12/17/10 (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 845-4~4-0800 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) www.wcb.state.ny.us 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 FALLS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~''i?L~2iQEi: CC3V~RE=~:~BY:~THi~:~C~€~71F:FGQ~f~.'•>::~:~:~': >: :::::::::::~; •za~~~>~:::~4:::~~fz~~:~r~r~ ::::::::::::::::::::::::::: POLICYHOLDER BLUE HAVEN POOLS NY INC 11 PADDOCK DRIVE - SUITE B CHESTER NY 10918 POLICY NUMBER +W 2082 626-9 DATE 12/08/2010 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 12/28/2010. 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. UU~V~ ~~ V ~D oEC 13 2010 CANCELLATION U-26.3 TOWN OF WAPPINGER TOWN CLERK THE STATE INSURANCE FUND ~~ ~~~ DIRE OR, INSURANCE FUND UNDERWRITING 979 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 ~` ~ ~ ~y ~~~~~ TOWN OF WAPPINGER ~/~~ 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 SEC ~ ~ ?010 rowN °F wAP T ~~wN CLE 1 NGFR ._T_._.~_RK ~:~:~1?ER POLICYHOLDER RICHARD J DELUCA DBA Al REMODELING EXPERTS BY DELUCA HOMES 18 PETERS RD HOPEWELL JCT NY 12533 POLICY NUMBER +A 1447 622-0 DATE 12/07/2010 CERTIFICATE NUMBER 429-535 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 12/27/2010. 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 ~~ DIRE OR, INSURANCE FUND UNDERWRITING 651 STDCAN-2/2001 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 1378 994-6 DATE 12/06/2010 CERTIFICATE NUMBER 965-399 ::::::p~€2iQf~::EO~//1rl~R~~jd::yf~i~Yy` tWsl~~::~~t~'f:1~:1yG;4t~ ::::::::::::::::~::: ~: ~:,:. `:. Z ~:~: ~ {.;~~ ~V:::,(:.tit:.: _:.4,f:~:~: j_~~f: ~:.:.:,:.> :.:.:.:.:.:.:.: POLICYHOLDER RENNHACK & RENNHACK CONSTRUCTION INC 14 CAROL DR HOPEWELL JUNCTION NY 12533 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. 1378 994-6 UNTIL 2/11/2011 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 2/11/2011 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 NOR INSURANCE AMEND, EXTEND OR IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT ALTER THE COVERAGE AFFORDED BY THE POLI('-'t ~: F U-26.3 1755 G~CC~[~OM~D DEC 0 9 2010 TOWN OF WpppINGER TOWN CLERK THE STATE INSURANCE FUND ~~ DIRE R, INSURANCE FUND UNDERWRITING CERT02-2/2001 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 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 12/06/2010 CERTIFICATE NUMBER 174-621 ~:~:~:~i?~€i1QE9:~6011~R~d:~ SY:~?WIs:~E~RTI~::{GA7~~:~:~:~>:~:~:~:~:~: 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 12/26/2010. 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~C Obf ~D ~ DEC 0 9 2010 ~~~` ~ ~ TGWN OF WAPPINGER T~~-~ERK THE STATE INSURANCE FUND CANCELLATION ~~~- 1~~ U-26.3 DIRE OR, INSURANCE FUND UNDERWRITING 1963 STDCAN-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 WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1448 745-8 DATE 12/06/2010 CERTIFICATE NUMBER 175-923 :~:~:~PL~2iQt3.'•EC3rt~R~d`SY:~tWIS:~C~€tTIK:ICQt~~:~:~:~`':~:~:~:~: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 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 12/26/2010. 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 G°~[~C~C~OML~D DEC 0 9 2010 TOWN OF WAPPINGEF TOWN CLERK THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING 1965 STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTENSIGN, 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 12/06/2010 CERTIFICATE NUMBER 526-941 :~:.:.>PE~iit?E3`CC3~REd:~f3Y:~ YHi~:~~~€~11~:~G.~~~~:~>:~:~:.:~:.:~: 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 12/26/2010. 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. _~~~ . 6 G~I~C~[~~~CD CANCELLATION U-26.3 DEC 0 9 2010 TOWN OF WAPPINGER TOWN CLERK THE STATE INS U RANCE FUND ~i~~ ~ ~ 1~%/ `. . DIRE OR, INSURANCE FUND UNDERWRITING 1943 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 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ::~1?~€ilfxf3:COI~RE~:~SY:~?WIS:~E~Ft7'I~:FGA7~~:~:~:~:~:~:~:~:~: ::::::::::z~:s:~~~~y~:::~~::::::~f:~:t:s~~r~ ::::::::::::::::::::::::::: POLICYHOLDER RENNHACK & RENNHACK CONSTRUCTION INC 14 CAROL DR HOPEWELL JUNCTION NY 12533 POLICY NUMBER +A 1378 994-6 DATE 12/06/2010 CERTIFICATE NUMBER 119-170 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. 1378 994-6 UNTIL 2/11/2011 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 2/11/2011 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 CERTI ICAT~;~~~~~~D +F DEC 0 9 ZO.O TOWN OF WAPPINGER TOWN CLERK U-26.3 THE STATE INSURANCE FUND ~~ DIRE R, INSURANCE FUND UNDERWRITING 1817 CERT02-2/2001 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 "::1?C~€#1QE1:: E(71C~R~C~> $Y: ~ tWl ~: ~ ~~€tTI~:FG~4~'~~: ~>: ~»: ~: ~ :: ~: POLICYHOLDER SBI CONSTRUCTION SERVICES INC 7 VETERANS PLACE WAPPINGERS FALLS NY 12590 NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 12/26/2010. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. C~; CANCELLATION U-26.3 POLICY NUMBER +A 1424 417-2 DATE 12/06/2010 CERTIFICATE NUMBER 348-067 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS G°~[~~i~OM[~D DEC 0 9 2010 TOWN OF WAPPINGER TOWN CLERK THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING 1543 STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ~:~:: i?C~tiQE3:~EC31l~R~r~:~$Y:~tHiS:~~~€fiT:IK:~GRtf~:~:~:~:~:~:~:~:~:~: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 12/26/2010. 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 CANCELLATION U-26.3 POLICY NUMBER +A 1448 745-8 DATE 12/06/2010 CERTIFICATE NUMBER 368-565 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ~~~, DEC 0 9 20 ~0 TOWN OF WAPPINGER TOWN CLERK THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING 1937 STDCAN-2/2001 c;ert117cate of NYS Workers' Compensation Insurance Coverage Page` 1 of 2 STATE OF NEW YORK WORKER'S 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 Dutchess Building Specialists Inc. 914-485-8343 488 Freedom Plains Road Suite 130 lc. NYS Unemployment Insurance Employer Poughkeepsie, NY 12603-0000 Registration Number of Insured ld. Federal Employer Indentification Number of Insured or Social Security Number Work Location of Insured (Only required if coverage is specifically limited 141735231 to certain location in New York State, i.e. a Wrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Instuance Company Town of Wappinger Building Department 36. Policy Number of entity listed in box "la": 20 Middlebush Road WWC3018405 Wappinger Falls, NY 12590 3c. Policy effective period: 12/1/2010 to 12/1/2011 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 Certification 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 !0 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, 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: Henry C. Sibley (Pri~ntwna~me of authorized representative or licensed agent of insurance tamer) Approved By: ~` ~ ~ 12/3/2010 (Signature) (Date) ~~ / ~. Title: Underwriting Manager C-105.2 (9-07) Telephone Number of authorized representative or licensed agent of insurance carrier: CarrierPhone Ptease Note: Only insarance carriers and their licensed agents are arthorized to issue the C-/05.2 form . Ltsnrance brokers are NOT authorized to issue it https://agentswc.amtrustgroup. com/PolicyNYCertificateOf WcIns. ~~C~[~~ML~D DEC 0 7 2010 TOWN OF WAPPINGER - T~~N CLER ~ Certificate ofNYS Workers' Compensation Insurance Coverage Page 2 of 2 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering 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. C-105.2 (9-07) Reverse https://agentswe.amtrustgroup.-comtPoli~yTll~Certf cateOfVVcIns-aspx?IndexId=21068 12T3%Z0 ~ 6 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 POLICY NUMBER +A 1378 994-6 DATE 11/26/2010 CERTIFICATE NUMBER 965-399 ::.:;:.p~tiaa:_cC3rt~i3El~:.$v:~ tHi~:.~~Etr~i=:cca3~ ::.:.:.:.:.:.:.:::.: POLICYHOLDER RENNHACK & RENNHACK CONSTRUCTION INC 14 CAROL DR HOPEWELL JUNCTION NY 12533 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 12/16/2010. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. G~C~C~C OML D CANCELLATION U - 26.3 DECO 1 2010 ~ ~e,, TOWN OF WAPPINGER f'~~'1 TOWN CLERK THE STATE INSURANCE~F~UND DIRE OR, INSURANCE FUND UNDERWRITING 2231 cTnr nni_7 inn ~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1378 994-6 DATE 11/26/2010 CERTIFICATE NUMBER 119-170 :~:~:~1?~€t1QE>:~E01(~R~D:~$Y:~TWIS:~C~t~7'I~:ICAT~~>:~:~>:~:~:~:~:~: POLICYHOLDER RENNHACK & RENNHACK CONSTRUCTION INC 14 CAROL DR HOPEWELL JUNCTION NY 12533 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 12/16/2010. 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 DEC p 1.2010 TOWN OF WAPPINGER ---T~wN CLERK THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING 2309 ~mcati-~i~nn 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 VILLAGE OF WAPPINGER FALLS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ::?~12~€21QE3:~EC3Sl~REb:~BY:~?WI~:~lr~f{TIF:EGA3~ :~::~:~:~:~::~:~: ~::~:~:~:~z~:~:X ~~~~d~:~~l~:~:fief:s6/:~~r~:~:~:~:~:~:~:~:~:~:~:~:~:~: POLICYHOLDER RENNHACK & RENNHACK CONSTRUCTION INC 14 CAROL DR HOPEWELL JUNCTION NY 12533 CERTIFICATE HOLDER POLICY NUMBER +A 1378 994-6 DATE 11/26/2010 CERTIFICATE NUMBER 965-426 VILLAGE OF WAPPINGER 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 12/16/2010. 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~~' CANCELLATION U-26.3 DEC 01.2pip T~lNN GF WAPPINGER THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING 2203 STDCAIV-~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 WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY 12590 ::~:~>;~€tiati:~E01l~RED:~f3Y:~fiFIIS.'•E~r~T:I~:FGQ3~~:~:~:~:~>:~?`:~: :~:~:~:~8~:431~~:1f~~:~~1~:~:~~~f:f6:l~~G~~Q:~:~:~:~:~:~:~:~:~::~:~:~: POLICYHOLDER EU-TE DESIGN LLC D/B/A EURO TECH CONSTRUCTION 181 BOYD ST MONTGOMERY NY 12549 POLICY NUMBER +W 1329 868-2 DATE 11/26/2010 CERTIFICATE NUMBER 287-068 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 12/16/2010. 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 ~~ DIRE OR, INSURANCE FUND UNDERWRITING DEC ~ 1:.2010 AWN ~F ~NAPPINGER ._..~ .-- T~ ~,N _CLER-~_ THE STATE INSURANCE FUND 2079 STDCAN-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 TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~: ~>.'• P C-€~iQE3 `E (3rt~ Rib: ~ 8Y.'• TW I S: ~ ~~€~TI ~:ECa3f ~: ~: ~:: ~ : ~: ~ : ~ : ~': - _ __-- POLICYHOLDER EU-TE DESIGN LLC D/B/A EURO TECH CONSTRUCTION 181 BOYD ST MONTGOMERY NY 12549 POLICY NUMBER +W 1329 868-2 DATE 11/26/2010 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 12/16/2010. 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. cony V ~'D SEC ~ 1:°2010 TOWN OF WAPPING -_..~ _~ ~1~~r ~~_ ARK ER THE STATE INSURANCE FUND CANCELLATION U-26.3 ~~ DIRE OR, INSURANCE FUND UNDERWRITING 2075 STDCAN-2/2001 STATE OF NEW YO)tK WORKERS' COMPENSATION BOARD ~~ r CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) lb. Business Telephone Number of Insured R L Baxter Building Corp 845-471-1047 54 Garden Street lc. NYS Unemployment Insurance Employer Poughkeepsie, NY 12604 Registration Number of Insured Work Location of Insured (Only ~quircd ijcoverage is speci,/lca/ly ld. Federal Employer Ideatiflcation Number of Insured limited to certain locations In New York State, ie., a Wrap-Up or Social Security Number P°itcy) 14-1652797 2. Name and Address of the Entity Regaesdng Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Pacific Employers Insurance Co Town of Wappinger 3b. Policy Number of entity listed in box "la" Building Dept. C4fi389153 20 Middlebush Rd 3e. Policy effective period Wappingers Falls, NY 12590 11/09/10 to 11/09/11 3d. The Proprietor, Partners or Executive Officers are included. (Only check box H all partnenloPRcera included} © all excluded or certain partners/officera 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 of premiums 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 Certificate. (These notices may be sent by regular mail.) Otherwise, this Certiftcate is valid for one year after this form is approved by the Insurance carrier or its licensed agent, or anNl 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: Approved by: Title: `a o are r e. M, U t S 2. (Print name of authorized repcesentetive of licena agoat of insuranoo tamer) /YLt~ ~ a1 ~Cl ~ e•r~ t~tJ r - ~-,' n 1- ZU- 1 0 (Hate) M «,n a ~t er ', °11 ~- ~ 33 y l 33 Telephone Number of authorized representative or licensed agent of insurance carrier: Please Note: Only insurance carriers and their licensed agents authorized to issue it. C-105.2 (9-07) authorized to issue Form C-105.2. Insurance brokers are NOT ~~~~D~ ~n www.wcb.state.ny.us N01! 2 920;:7 TOWN OF WAPPINr~o Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts uuleas compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required bylaw to issue any permit for or in connection with any work involving the employment of employees in a hazardous employmerrt 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 carver 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 subscnlxd 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