2010 (4)NEW YORK STATE INSURANCE FUND
1 WATERVLIET AVENUE ~XTE~TSION, ALBANY, NEW YORK 12206-1649
1518)) 437-6400
CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
~~ TOWN OF WAPPINGER
BUILDING DEPARTMENT
20 MIDDLEBUSH RD
WAPPINGERS FALLS NY
12590
:~:;:::.RL~2iQd:.C011~i2~b:.$y<mHis:.ir~[~t'I~:FGA~'f ::.:.:.:.:.:.:.:.:.:
POLICYHOLDER
LIPUMA CONTRACTORS, INC.
9 BIRD ST
RED HOOK NY 12571
POLICY NUMBER
+A 2075 343-0
DATE
1/20/2010
CERTIFICATE NUMBER
657-518
CERTIFICATE HOLDER
TOWN OF WAPPINGER
BUILDING DEPARTMENT
20 MIDDLEBUSH RD
WAPPINGERS FALLS NY 12590
THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER
NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/09/2010.
THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF
INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY
ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS
NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT
AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY.
~F,,
.- ~ JAN ~ ~ 2010
W
-~~n-t~~ ~;I_F~'
CANCELLATION
U-26.3
THE STATE INS~U~RANCE~F~U`ND
~,~~ 1~%l Q/~Eiliti`
DIRE OR, INSURANCE FUND UNDERWRITING
4SQ
NEW YORK STATE INSURANCE FUND
1 WATERVLIET AVENUE XTE SION, ALBANY, NEW YORK 12206-1649
~518~ 437-6400
CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
TOWN OF WAPPINGER
20MIDDLEBUSH RD
WAPPINGERS FALLS NY 12590
:~:,:.:.P~2iQd:;CC3.rl~i?~t?:.$Y ~tWi~:.it~€t1~I~:IGa~~~::.> :.:.:.:.:.:.:.:
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 ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER
NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/10/2010.
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.
~~ .
,~ ~o
~~ _;~
~~ ~~
~'
CANCELLATION
U - 26.3
POLICY NUMBER
+A 1482 281-1
DATE
1/21/2010
CERTIFICATE NUMBER
668-155
~E~~~~~L
JAN 7 5 2010
THE STATE INSURANCE FUND
~~
DIRE OR, INSURANCE FUND UNDERWRITING
~~~
~~'ORkr.TtS' ~'{~ti'Lt'L~JSATIt}l~ I3C~:".T<73
~ ('N'.Jt'I'I.h'.I.C _~.'1'L f3t' iNSL'RAV~C'F C`i')V'F:JI~AGl+: U1D1•R TAF. `•'4'S I).t5~~B1LI'I'YBF,Nt:t•I•i'S L.~i~'4
P.4F~'I~ 1, 'I•o be cuJaslJleteti b~~ Diti~rbility 1fle~r,efitx i'J>~rrie;" ttrLiecascd Insnrsi;tce Agent of ihAt Carrier
1:;, Le,~:tl ~Jx[nc an~j ?,~lclrc;ss i+J'linxurcxi {T.J,~e etf?ei itdcll'e55 0[11~~) 1 •.~.13utiincti~ Te~eplla.~e lumber c±l' In~~ircd
(845) 635-2102 x
Mr Rooter of Dutchess County Inc 1c. NYti l.:nKUiplt~yn~cnt Itrsurancc }•:i>!tJ71Cy'Cr i~cgisuxt'on
West Road 'Nul~tbertJf ir>surti:il
09-125368
Pleasant Valley, NY 12569 ld. Fcd~7~xl F.Inplvt'er l~ientir[;xtiurJ lumhc•r [~fl•nStJA'ed cr 5u~•ixl
SrLUl•Jtti' ~lUrrIE1C]•
• 14-1797372
2, Name and.addres:; oftha L-utityRetluesllug 1'ruu"ol'C[n•Lva~z 3a. Rrmc ctif lnsur;tn~e C'arrizs -
(Fnlil.}~ 1Flcing T.itilcd liti Ih~ t"'crtifir~ane Hnlcer} Guardian Life Insurance Company of America
Town of Wappinger
20 Middlebush Road 3h. Polio?~ •~ltintbc:' of Cr[tiiti' listed in I•,nx " I ~!";
• 00969092-0000
~c. PUlic.~ eftecti~~ t~=l'u+d:
Wappingers Falls, NY 12590 12/31/200 ~to , ' ~ 12/31/2010
•1. PaJicy ~~~+~~rs:
JAN ~ 9 2010
il.~ i111 oFihc rtnp:c~.~ar Cll]1+lc+yccs ll1~+11;?{2 t1111~Z1: i11C ~C4S' ~•W'k DI!>Ht11111\~ $l:n;:I1L.~ Till+'
• =''~1f1/!fit (;~. FPr
h,^ (}r,ly 4hc: fiy lo~~'in~::Iast nr classes oftli~entpln;~er's er~ip[ay~a:
Under penalty p. perjltn~,1 ce:llti~ aril I arr[ srJ auth~Jriu~[1 rr.•}~n~,:utliti+~.. [ll- liccn;cd ;t=ent ~tif tlrP rn~urancP ::Y7rrirr rrli:~•c~ic:cd abnvz ant
ttr.tt the naincd insured ha; ?~IYS TJi~rahility Rcnetita in5'slriUtce co~'e:age Ss •~ast::ibe~l nbo~•~.
,~ / ~
~~~~~ '
. 1/14/2010 By. ~1
(Si rrst:.r~ ut'in9~u•Hr.: Y+'T7Cr£ 9l•[I14riZJ. 'Cp0.~clt',l'luc oC 1'Y'~ Li.~tis~5~'., L,S li~~yt r~E+~~t u: ltu: :n~u~•~e-::r c%rne+-1
516-482-2696 Title r' "° r ~ ` ~ - •-•••
T2lepltiooe Nambcr ~, __._
Ilvll'(ritf,'INI tlLu> "~~" -' ^: n:ka'],nud IBIS t(d'1111'. Sih~ Cfll1•y lii,: ~i,<ulfluC::Ct]iiiir'4aulLiui•ra:d n:pn:¢:• ~&~i•.::C~i VYt T.ii:~:n~i:J Tisui:u~~t: ~Ni~.a ~: lnMl. e:uria:. i:ia
~:zrtil=catcisC'C1hti'Lt'l'k.. Mini;i-dira:.']y[c~-'•c•arrJ-i~;~[choldcr
lib~x "3b" 16 Cht~i•:~CL, [Itl$ ~ •[I'IC;itC it h[I I ['tll~tl'I F.I'F:fOr ;nn•I+r~Ci ~f 5;,.:'ipn :Jj,tiUx1• •i nftPr. U tal+ilirv Hcuafir5 ~•~'h' II dYll~t ;+C ;[411ttl11 JAC
t~cnrplr[:uu.u !hr V~~uikat' C'wupcn>•aliu:• L1;+ait~. DTi i9pne ;1~~rp~pn[•8 irr'l: ^V T't+''e SI•r~>.;, :~thanv, lau• Yo ~k I ".~07.
PAli'1' 2. To tre crmpte.tecl b~'_VYS ~~'OCk{'X5~ {'OTCl~cn5A~14n RoR~'cl {[)nl~~ if hm "=-lh" of I'i9rt 9 hsr>~ I~r.~n r.hcrkrd)
_.. .._ ~-tate t7f hTew'4~urk
1.~'orl.ers' CoEn~reusation I#aarcl
;l ccord~ ~~ to infnnnr+tinr, m:rinknl~uri h~~ thr. ~JY"~ l§~e7r:rKV' C:nm~c:n~~rtits~ 13.urr,T; t5~: ahnvr~nsm-•ro•T rhnplm~rrhrr: ;:nmPTiexl ~t•iti~'hP 1~ 1 (115~~11,'t~[•
T3c~n::iit~ Tanv ~ti•irtr ~elpect «all nl•Iti~:lter zrnltilayec~rt.
Data Sigruxl ...__-- ~'`'
_-_._. .. iS ~ :•..iv vi ~Y~ V~•uck:~= C:o:np~a:t[iun l3varJ ;:m~+l:,}~erl
'l~zlephoue 1~lutnber 'title _.._
PlErrxr tVofc: Utrlr irrsurttn~c~ c't:rnc~J•,a Ict:Y.)tsf:rl to 1~,°r:;~~ rb7'S rz~n(r,'?i#~ hc~nP.,fi:s r~7surcYr~r[~~o1i_~~r~ :tnc$~4`f'S fdc'c',n.stal itrs•2r~aru'~~rr,:;~rts ql
tlrrte ir,eao'anr,~ ..^arrs~'~' r:rn. aur)!rt'~~r?~1 rr, J:s; , : /•'rrn~ 1}ii-.(J`.J..(. ti2Srr1'17riCN brc~krrs arr..'%!1!'rrutllur~2ert try iYS~~e this fnrm.
1313-1:iG 1 r4-Ohj
~dcliti~~nal Iyi~;firtJt:.ti~ms fir r'orrn DLi-12~, t
By signing thi, foizn; the incUt'.1.ItCC cttrri.:•r idcntificd i n l}c~K '';'' un tJtia ti~nr is ccrtif<<iu~; ~iJ~,~ it iy i[isurint; the buell~tss
•referertre~( irtib4tix ''la" lur disttUilitr ~enefitx undtrr I.}lt: \wn~ Y[~rlc Sratz 1)i,cq(~iii6~~ J3~~n[:fits .I.a~v. -E'hc ln~~ur~inc:c ~.t1ffICC ar its
licenszd ~gc[Jl will ~cnd thi, fer#ific7~te oflttsur~tat ~c~ the zntiit~ li~tzcl!;ts the ~t._lilic~tu 1•.nl;:~er i~ took _Z". This {:e!r1i/J:cult?u
~+allri',J'~r the ~ariu:r uj ~~~leyrrir a•~3Pr ~ku, fva•,~ rs rYppt-nt~ed h3~ t,§r irJ•criraayre c.'arrfe~p or iJ~ Fr['eJ~tti~ed rr;n.>'rt, or 1h e) pulse t' r~uJ~o~taotr
rdrrtc lisr~d iJ~ hrrx ".3c".
PJca~r Aot;_: IJrun thcaamctll,.tion Jl~~~e ~iisflbililp h~~wh'its pelu;y n~dieat~d au lhi:; Ji~rrn, it'th:1>UsutC3s CGC!'.J>7uar, lu bG;ifvned oJ1~ ~~C.mit,
lisn•,Z .)r uF.ilrau.i~~•,,ctii by n ccrttfi~3>L Ital~r, the husir4iy mus-pral-tde Cs12t car1lGcrn,e h;sJ::t.•u••th ti ;ieu' C•er~ifirstt~,:CNYS 7~i:;btltry
BcnnfiLr• C'o~•cru~e car ether rssthorz: ti pruuJ tJsat ll;r LtG,Li~:;~ ;~ t:cnnFilti~igg +vitlt [ire nu~tltC3:,~rv er~vrisi~-r. t:.yutn,~tuent~ of the Kn-ti• •Y~+tk State
13;snL~ili[5~ 13er~eGls Luw_ ~ •
:I~1~.A~ilL~T~' BT•~lT~',F:X'~.~5 LAM'
§2~0. Sued. 8
{a) The he~u{ of a s#ate or munici~a' ~p~~rtmei3t, l~~~rd, c~r~~.i4sion car t~Ilice r~uthc~ri~ed ~,~c r~.quir~ by lar,~,~
tt~ issue any pcimi~ liar ear i» ccm~~ectian with any ti;~srrk i:~~.~c~l~•in~ th4 ~>mtrio4Yinvnt ~ t en~~,lc~}~e~s in
empJc~ymer~t as J~efincd ixi this Artic;lc:; ~3n~i nc~t ~vit'.~standi.gg ally ~crit;ral or :;pec;i~il star3tz re,.~uiring ur
~tulhUriciu~ the issue c?f such perm itg, shJ~~ I i~s~t issue; such pcmlit un~as~ l~rc~nf drily subs~:r=bccj b,f an
insu,rarice carrier is produced irl a f'anrl tiatisf•i~ut~t~y tc} the chair, ttJ.at the pa}-[Hens c~1'tii,ability bencfit5 far
~l! ~~rn}~lctiyecti hay; heen ~;ecu~~eci ~JS provided ~y this artier. ?~nihin~ h~.~t-ein; hc~~l~~ver, ~t-iall be eor7struccl ~~
c;l~fltin~ Any liability nn tho l.~art of'such stag ur muni.~ip<<l department, hoard, c~mrrtiasia~~ or ul~'icae t<~ ~J~,y
flil4` disability benefits to any such em~lioy~c i f cry emplctyt~,
(by I"hc head ui a stafc car 1Y~uniLip~t1 ~tipYu-1mci~t, hc~drd, c:cnnmi5sit~tt sir c7f~-ic~e ztrt.fat~J'iZed ~~r rc~7uii~d by ]x~~•
to eutzr into aJl}' ca~ttrdl,.t for a~- iii C::"~:'.i1~CtiOr1 ~741t~1 a`~rly' cw urk ir~vc~lt•a11+~ life :;Ini~l~yyrnenl c~ I' errl~lc~vccs in
emplc~~)Jnc~it as dcfii2cd in titre articit:•; ~~nd nai~,vithstaulcii»~ any gzneral [>r special st>;Jtute requiring ter
authc~riiing any :;uch ctfntr~tct, rh~~1l r~crt enter ii~tn an;~ wUC~l C{71711"sltc:t L111~~,5G ~,ll"qOt du1;- subs~ribod [~~• ~ll
insuraticc carrier is prc~duccd in ~ form Sati~thctary to the c~'Jair, Thai the payment off ciisabi,lity bc,~cfits for
f~~l emi~loy~4 h~,~ been se~•t~red as pxt}4•ic~ti by this turtic•lz.
JAi~ h
~~~~'^' ~a ~~
T)R-I).1l I (i-fin)
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1a.legal Name and address of Insured iUse street address only} 1.b Business Telephone Number of Insured
Eastern Heating & Cooling, Inc., a 518 465 8878
Comfort Systems USA, Inc. Company, 1.c NYS Unemployment Insurance Employer
Registration Number of Insured
880 Broadway, Albany, NY 12207
ork Location of Insured (Only required if coverage is 3072396
pacifically limited to certain locations in New Vork State, i.e. a 1 d. Federal Employer Identification Number of
Wrap-Up Policy) Insured or Social Security Number
141713597
2. Name and Address of the Entity Requesting Proof of 3.a Name of Insurance Carrier
Coverage (Entity Being Listed as the Certificate Holder/
Indemnity Insurance Company of North America
Town of Wappinger 3.b Nolicy Number of entity listed in box "1a":
20 Middlebush Road WLR 045705997
Wappingers Falls, NY 12590
3.c Policy effective period:
11/1/2009 to 11/1/2010
rr
~G~~~~ ~~
~ ~ 2~1~ 3.d The Proprietor, Partners or Executive Officers
JAN are:
~,n~n-n! ~I_FD~
X inClUded. (Only check box if al! 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 "1a"
for workers' compensation under the New York State Workers' Compensation Law. iTo use this form, New York iNY}
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 1F a policy is canceled due to
nonpayment of premiums or within 30 days lF 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 eeilier-
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 anew -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.
C-105.2 (9-07{
CK-404 0 (9/071
Workers' Compensation Law
Under penalty of perjury, I certify that 1 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: Janet O'Donnell
iPrint name ofa(u~-onzed representative or licensed agent of insurance carrier)
Approved by: ~ /~-/ ~ ~ _' /oZ - ~
Manager SDate)
Title:
Telephone Number of authorized representative or licensed agent of insurance carrier: 302-476-6181
P/ease 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.
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.
~~~~4~ ~~
JAN 1 ~ 2010
•~~nrn~ ~',1 Fp'
C-105.2 i9-07)
CK-404 D i9l07)
STATE OF NEW YORK
~- WORKERS' COMPENSATION BOARD
CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW
PART 1. To be com leted b Disabili Benefits Carrier or Licensed Insurance A ent of that Carrier
la. Legal Name and Address of [nsured (Use street address only) lb. Business Telephone Number of Insured
LORI M WAREING lc. NYS Unemployment Insurance Employer Registration
109 STAGECOACH PASS Number of Insured
STORMVILLE, NEW YORK 12582 2322171
ld. Federal Employer Identification Number of Insured or Social
Security Number
14 1804203
DBA: LORJEN ELECTRICAL SYSTEMS
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 WAPPINGER 3b. Policy Number of entity listed in box "la":
20 MiDGLCaUSH RvAC ~ 17o$i40
WAPPINGERS FALLS,N.Y. 12590 3c. Policy effective period: ~ C~ ~ ~ ~ f
C ~J
O1/O1/10 to O1/O1/11
4. Policy covers: I f w,
a.® All of the employer's employees eligible under the New York Disability Benefits Law ~~4~n1 rl ~~"
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.
~~ `~
Date Signed 1/8/2010 By
(Signature of insurance cazrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier)
Telephone Number (631) 845-2200 Title Administrative Services Manaeer
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 "46" 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 Accepiattce unit, 20 Park Sireet, Alba~~y, New fork 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 Boazd 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)
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 inbox "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 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 departrent, L-oard, co~nniissior~ or office authorized or required by la~v
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.
v-tECEI~f ~-~
JAN ~ ~ 2010
-~~~r~~ r~ ~~~
DB-120.1 (5-06)
s 1 A'1'Jr U!i' 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
Chazen Engineering, Land .Surveying & 845-454-3980
Landscape Architecture Co. PC
21 Fox St
Poughkeepsie, NY 12601
lc. NYS Unemployment Insurance Employer
Registration Number of Insured
Work Location of Insured (Only required if coverage is speck ld. Federal Employer Identification Number of Insured
limned to certain locations in New York State, i.e., a Wrap-Up Poll or Social Security Number
14-1681699
2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier
Coverage (Entity Being Listed as the Certificate Holder) Hartford Fire Ins . Co .
3b. Policy Number of entity listed in box "la"
Town of Wappinger 16WECF03422
20 Middlebush Road
Wappingers Falls, NY 12590
3c. Policy effective period
~~ ,~` ~' ~w~v
-%' ~ ~ GG~ 12/31/09 to 12/31/10
`t~V r~ 1 ,yo10
~AN `
1~ 1
-^`nl~I (',~ ~'~ 3d. The Proprietor, Partners or Executive Officers are
®included. (Only check box if all partners/oftcers 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' compensatio
under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on th
INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificat
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 of premiums o
within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverag
indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form: i
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
permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate o
Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirement
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 abov
and that the named insured has the coverage as depicted on this form.
Approved by: Gerald .M -Brown Ulster Insurance Services, Inc.
(Print na of aut rized re entatrve or licensed agent of insurance carrier)
Approved by:
(Date)
Title: Senior Vice President -Insurance
Telephone Number of authorized representative or licensed agent of insurance carrier: fi45-X38-h000
Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105, 2. Insurance brokers are NOT authorized L
issue it.
C-105.2 (9-07) www.wcb.state.ny.tts