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1987/2007 (13)THE STATE INSURANCE FUND 199 CHURCH STREET NEW YORK, N. Y. 10007 (212) 312-7249 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING 106 REEVES STREET GLEN PK, WATERTOWN NY 13601 RERI(bD::Cf7VERE{3::B.K: 'HIS CERTIFIC1.iTE::::_'::;::::;:.: i~~o~~a~ rz~: ro~~isr POLICYHOLDER JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING 106 REEVES STREET GLEN PK, WATERTOWN NY 13601 POLICY NUMBER ,. Ci5? t 5F_, DATE 9/20/91 CERTIFICATE NUMBER 890-891 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 10/14/91. THIS TNFORMAT?ON IS FURNISHED YOiJ TN 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. CANCELLATION THE ST-A~TiE INSURANCE FUND /9` . C~~ DIRECTOR, INSURANCE FUND UNDERWRITING 470 THE STATE INSURANCE FUND 199 CHURCH STREET NEW YORK, N. Y. 10007 (212) 312-7249 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING 106 REEVES STREET GLEN PK, WATERTOWN NY 13601 P~ RIO D :. >rO:V.E R ED::: B1!:.:~'H I.S:::CE R7IF I C RT E::::::.:.: f.~l4Z189 T17:1Q.11:~191 POLICYHOLDER JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING 106 REEVES STREET GLEN PK, WATERTOWN NY 13601 POLICY NUMBER ''` 953_156-7 DA~~E 9/20/91 CERTIFICATE NUMBER 890-890 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 10/14/91. 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. CANCELLATION THE ST'A~TiE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 469 THE STATE INSURANCE FUND 199 CHURCH STREET NE'+/V YORK, N.Y. 10007 (212) 312-7249 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING 106 REEVES S'IREE'1' GLEN PK, WATERTOWN NY 13601 RERfO D:. COV.EREfl:::61~:::fiHIS:::CERTIFIG~jTE :::::::::::::::::::: f ~!l:~T:189::FD;:1lI:1:1:?~l:gl::::::::::: POLICYHOLDER JACKALYN BOYLE D/•B/A AMERICAN ROCK EXCAVATING 106 REEVES STREET GLEN PK, WATERTOWN NY 13601 POLICY NUMBER ~~ 953 156-7 nnTr- 9/20/91 CERTIFICATE NUMBER 890-889 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 10/14/91. 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. CANCELLATION THE ST'A~TiE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 473 THE STATE INSURANCE FUND 1'a~~+ CHURCH STREET NE'J`J YORK, N.Y. 10007 (212) 312-7249 CANCELLATION OF CERTIFICATE OF WORKERS' COYIPENSATION INSURANCE TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 PERf~D C~:VERED BY THIS. CERTIFICATE >~14?~89 T0: 7I0~191 POLICYHOLDER JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING i coNTI Box 3666 KINGSTON NY 12401 POLICY NUMBER '` 953 156-7 DATE 6/10/91 CERTIFICATE NUMBER 890-889 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 7/04/91. 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, CANCELLATION THE STA~TiE INSURANCE FUND /9` . C~~ DIRECTOR, INSURANCE FUND UNDERWRITING 247 THE STATE INSURANCE FUND 199 CHURCH STREET NEW YORK, N.Y. 10007 (212) 312-7249 CAtiCELLATION OF C'ERTIFIC'ATE OF WORKERS' COMPENSAT[ON INSURANCE JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING coNTI Box 3666 KINGSTON NY 12401 PERIOD C~:V.ERED.:B.`f THIS:::GERTIFVCATE, a~14?l8g.T17: 7/44/91 POLICYHOLDER JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING i coNTI Box 3666 KINGSTON NY 12401 POLICY NUMBER ~~ 953 156-7 DATE 6/10/91 CERTIFICATE NUMBER 890-890 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' !;OMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 7/04/91. 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. CANCELLATION THE STA~T~E INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 248 THE STATE INSURANCE FUND 1'a~-'' CHURCH STREET NE`/`J '(QRI:, N. Y. 1000? (212) 312-7249 CANCELLAT[ON OF CERTIFICATE OF WORKERS' COVIPENS~T10~ I.~~SI;RaNCE TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 POLICYHOLDER PERIOD Cr~~VEREfl BY THIS CEFtTIFICAT'E (.2/07/89 TO 7/04/91 JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING CONTI BOX 3666 KINGSTON NY 12401 POLICY NUMBER '' 953 156-7 DATE 6/10/91 CERTIFICATE NUMBER 890-890 CERTIFICA)-E HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 7/04/91. 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. CANCELLATION THE ST'A~T~E INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 246 THE STATE INSURANCE FUND 1`39 CHURCH STREET NEW YORK, N.Y. 10007 (212) 312-7249 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING coNTI Box 3666 KINGSTON NY 12401 PERIOD C©VEREU B`f: THIS CERTIFIC,4TE f~14?189 TD 7/04/9f POLICYHOLDER JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING CONTI BOX 3666 KINGSTON NY 12401 POLICY NUMBER ''` 953 156-7 DATE 6/10/91 CERTIFICATE NUMBER 890-891 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 7/04/91. 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. CANCELLATION THE STA~T~E INSURANCE FUND /7` . C~~ DIRECTOR, INSURANCE FUND UNDERWRITING 249 THE STATE INSURANCE FUND 1 ~'7 CHURCH STREET NEW YORN., N.Y 10007 (212) 312-7249 CANCELLATIO'V OF CERTIFICATE OF WORKERS' C'OVIPENSATION I'VSI~R,a~CE TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 .PERIOD C©VERE1~ BlF: THIS CERTIFICATE l2!I4?I89 TD 7/~~/9J POLICYHOLDER JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING CONTI BOX 3666 KINGSTON NY 12401 POLICY NUMBER ~~ 953 156-7 DATE 6/10/91 CERTIFICATE NUMBER 890-891 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 7/04/91. 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. CANCELLATION THE ST'A~T~E INSURANCE FUND ~'9` . C~~ DIRECTOR, INSURANCE FUND UNDERWRITING 245 THE STATE INSURANCE FUND 199 CHURCH STREET NEW YORK, N.Y. 10007 (212) 312-7249 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSI~RANCE JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING CONTI BOX 3666 KINGSTON NY 12401 PEFiIDD CO:VEREfl..B`F THIS CERTIFICATE f~I©?189 Tl7 ?l04/9i POLICYHOLDER JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING % coNTI sox 3666 KINGSTON NY 12401 POLICY NUMBER ~~ 953 156-7 DATE 6/10/91 CERTIFICATE NUMBER 890-889 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 7/04/91. 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. CANCELLATION THE ST-A~T~E INSURANCE FUND ~i` . C~~ DIRECTOR, INSURANCE FUND UNDERWRITING 247 THE STATE INSURANCE FUND 199 CHURCH STREET NEW YORK, N.Y. 10007 (212) 312-7627 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSLRANC'E TOWN OF WAPPINGER 20 MIDDLEBUSH RD P 0 BOX 324 WAPPINGERS FALLS NY 12590 PERIOD COVERED BY THIS: CERTIFICATE 314tf9f TO 3/41/92 POLICYHOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD P 0 BOX 324 WAPPINGERS FALLS NY 12590 POLICY NUMBER ~~ 056 278-5 DATE 12/19/91 CERTIFICATE NUMBER 962-967 CERTIFICATE HOLDER CO OF DUTCHESS PLANNING DEPT ATTN LORI HOLLAND 27 HIGH ST POUGHKEEPSIE NY 12601 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 3/01/92. 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. CANCELLATION THE ST-A~T~E INSURANCE FUND ~9` . C~~ DIRECTOR, INSURANCE FUND UNDERWRITING 300 THE STATE INSURANCE FUND 199 CHURCH STREET NEW YORK, N.Y. 10007 (212) 312-7249 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING CONTI Box 3666 KINGSTON NY 12401 ~, , RERfOD: CC7VERED::6~`f::THIS.:CERTIFICIXTE :: :::::: x!14?~89: Tl~~. 2%18/1 POLICYHOLDER JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING CONTI BOX 3666 KINGSTON NY 12401 POLICY NUMBER ~~ 953 156-7 2/04%91+ CERTIFICATE NUMBER 890-889 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION ;'OLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/2$/91. THIS INFORM.nTI0I4 IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. CANCELLATION :, - TIIE STA~TiE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 126 THE STATE INSURANCE FUND 199 CHURCH STREET NEW YORK, N.Y. 10007 (212) 312-7249 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 PERIOD COVEREfl B.`f THIS ::CERTIFI,CATE s~~a~~8s r~ 2~~B~~f PGLICYHOLDER JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING CONTI BOX 3666 KINGSTON NY 12401 POLICY NUMBER ~~ 953 156-7 DATE 2/04/91 CERTIFICATE NUMBER 890-889 CERT!F!CATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/28/91. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH. TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. CANCELLATION THE ST-AfTiE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 183 THE STATE INSURANCE FUND 199 CHURCH STREET NEW YORK, N.Y. 10007 (212) 312-7249 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING CONTI BOX 3666 KINGSTON NY 12401 PERfOD COVERED BV: THIS CERTIFICATE f~1©?I89 TD: 2/~B1~1 POLICYHOLDER JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING CONTI BOX 3666 KINGSTON NY 12401 POLICY NUMBER ''` 953 156-7 DATE 2/04/91 CERTIFICATE NUMBER 890-890 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/2$/91. 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. CANCELLATION THE ST-A~TiE INSURANCE FUND DIRECTOR. INSURANCE FUND UNDERWRITING 127 THE STATE INSURANCE FUND 199 CHURCH STREET NEW YORK, N.Y. 10007 (212) 312-7249 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 RERfOD, COVEREfl: 61f. TH15::CERTIFICATE f~!I©Z189 TD :. ?leg{gf POL DER JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING CONTI BOX 3666 KINGSTON NY 12401 POLICY NUMBER ''` 953 156-7 DATE 2/04/91 CERTIFICATE NUMBER CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/2$/91. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. • .. s K s' CANCELLATION THE ST-A~TiE INSURANCE FUND ~7` . C~~ DIRECTOR, INSURANCE FUND UNDERWRITING 182 THE STATE INSURANCE FUND 199 CHURCH STREET NEW YORK, N.Y. 10007 (212) 312-7249 "'° CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 . ., . REftfOD: C~:VERED::BY::THIS::CERTIFIGATE :: 12I~Z~89:.T0..2:/~8/g1. FOLICYI-IOLDER JACKALYN BOYLE D/B/A AMERICAN ROCK EXCAVATING coNTI Box 3666 KINGSTON NY 12401 ~ POLICY NUMBER ~` 953 156-7 DATE 2/04/91 CERTIFICATE NUMBER 890-891 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS WAPPINGERS FALLS NY 12590 . .. THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 2/2$/91. 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. CANCELLATION THE ST'A~TiE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 181 aJ 2 NEW YORK STATE INSURANCE FUND 15 COMPUTER DRIVE WF51~)A437N6~OOEW YORK 12205-1690 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD PO BOX 324 WAPPINGERS FALLS NY 12590 SEP ~ ~ 2~~~ . , ~ .. d~..~ _. . POLICY NUMBER +A 1324 085-8 DATE 9/03/2002 CERTIFICATE NUMBER 261-959 >::::::RL~Eti~a:~C;O.VER~C5:~8Y:;~WIB:~C~t~7~I~:FGa~tir~>:~>:~>:~:~:~::: POLICYHOLDER JEFFREY BUCCIERO DBA HUDSON VALLEY RENOVATIONS 119 COOPER RD FISHKILL NY 12524 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD PO BOX 324 WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 9/24/2002. 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. CANCELLATION U-26.3 355 THE STATE INSURANCE FUND .H,e~~, /n~, a~Kj~%G• DIRECTOR, INSURANCE FUND UNDERWRITING crnrnni_~i~nn~ NEW YORK STATE INSURANCE FUND 15 COMPUTER DRIVE W~51$)A437N6~OOEW YORK 12205-1690 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGER FALLS NY 12590 :~:~:~A~E#ir~aCO~~E[~:~f3Y:~~WI~:~~~r~1~I~:GC~~'~~:~:~:~:~:~:~:~>:~: :::::::::7~:2af~ar~~::::~:n::::::gF~~~~o..~2 :::::::::::::::::::::::::: POLICYHOLDER CARLOS GUAJARDO 1 LAKESIDE DR WAPPINGER FALLS NY 12590 POLICY NUMBER +A 1257 454-7 DATE 9/04/2002 CERTIFICATE NUMBER 154-660 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 9/25/2002. 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. CANCELLATION U-26.3 i i~ o THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING RECEIVED AEG -' 5 2002 STATE OF NEW YORK TOWN CLERK woRlcERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSUR ~C~E ,C~,,~~° la. Legal Name and address of Insured (ilse street address only) lb. Business Telephone 845-471-8700 ~ul ~ 1 ~~~~~ BLACKTOP MAINTENANCE CORP. 27 COMMERCE ST. lc. NYS Unemployment Insurance Emplo er~Re ~R Q u~U Number of Insured c POUGHKEEPSIE NEW YORK 12603 J TOVti~O~A Work Location of Insured (Only required ijcoverage is specifically ld. Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e. a Wrap-Up Policy) 14-1552157 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certifinte Aolder) MOUNTAIN VALLEY TNS . CO TOWN OF WAPPINGERS 3b. Policy Number of entity listed in boz "la": 20 MIDDLEBUSH RD WAPPINGERS FALLS, NY 12590 W3100079970 3c. Policy effective period: 6/1/02 to 6/1/03 PERFORMD -TOYOTA OF WAPPINGERS 3d. The Proprietor, Partners or Ezecntive Officers are: ^ included. (only check box if all parnrcrs/officers included) ^ all ezcluded or certain partners/oilicers ezcluded. 3e. Demolition is: (Defutition ofDenrolition on Reverse) ^ inclnded. ezduded. This certifies that the insurance carrier indicated about in box "3" insures the business referenced above in box "1 a" for workers' compcnsatiat under the New York State Woricets' Compensation Law. The Insurance Cattier 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 !0 days IF a policy is canceled due to nonpayment of premiuner or within 30 days IF there are reasons other tiwn nonpayment of premiums that wn~el ::~~ N~..~y ..~ t..%•.••.•-•~ •••~ ••~-"~-,r •~ - -- -- e indicated c- !t::s ~~,a ,^,tg. ~~s:S~ riv':iCB.w i,:uy ui 321~i ~y ir~ui(tr mali.~ VIRCTWISe, rRis Lcrti,/ieau u va[ia jor a maxiinutn ojont ytar after this jornr is approved by the insurance carrier or its licensed agent Please Note: Upon the nncellatioa of the workers' compensation policy iodintrd on this form, if the business continues to be named oa a permit, icerrse or contrail issued by a certlficate holder, the business must provide that txrtltinte holder with a new Certifinte 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 L.aw. 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. JANICE BALLARD Approved by: (Print name of viz Approved by: (Signature) n:presrntative or licensed agent of insurance carrier) 7/29/02 (Dau) Title: EXECUTIVE VICE PRESIDENT Telephone Number of authorized representative or licensed agent of insurance carrier. 845-896-4706 Please Nott: 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-Ol) NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 `: ~:`• 1?L~21Q1~>E~V~Ft~C~:.$Y:~ twig: ~;r~€t~-~:cc~a~~~':;: ~:.:;:.>:.:.: :~:::::::f~}J;O..~;l~~:~b:::F:~::;:;:8:~:19~~4~2 :::::::::::::::::::::::::: POLICYHOLDER ARMSTRONG ELECTRIC INC 4 IRIS COURT WAPPINGERS FALLS NY 12590 POLICY NUMBER + G 994 421-6 DATE 7/29/2002 CERTIFICATE NUMBER 336-865 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 8/19/2002. 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. CANCELLATION U-26.3 THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 623 STDCAN-212001 NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +G 1054 788-3 DATE 7/29/2002 CERTIFICATE NUMBER 139-061 :~:::::: R~€21Qt'3: ~ EClV~R~I~::$Y: ~ •.T.WIC:~~~t~."{'IK:EGA'C~ ::::::::::::::::::: :::::::::~~:a..~:f~a~:f::::~:~::::::s:f:~:~~.~0~2 :::::::::::::::::::::::::: POLICYHOLDER MAHOPAC FUEL CO INC T/A MAHOPAC FUEL CO P 0 BOX 869 MAHOPAC NY 10541 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 8/19/2002. 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. CANCELLATION U-26.3 THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 2231 STDCAN-2/2001 NY Transportation Workers' Compensation Trust First Cardinal Corporation, Administrator, 10 British American Blvd. Latham, NY 12110-1415 PROOF OF WORKERS' COMPENSATION COVERAGE ~~~~~~~ .~~t ~ ~. Z~~~~ Certificate Holder: Town of Wappingers Falls PO Box 324, 20 Middlebush Road Wappingers Falls, NY 12590 Plan Participant: Paraco Gas Corporation 2975 Westchester Avenue Purchase NY 10577 SUPERUISOR'SOFF1Cr TOWNOFWAPPINQER Date: 07/23/02 Policy Number: 120034-02 Effective Date: 01 /01 /02 Expiration Date: 01 /01 /03 This is to certify that the Plan Participant named above is insured with the NY Transportation Workers' Compensation Trust under the policy number and for the period indicated above. This policy covers 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, and with respect to operations outside New York, to the policyholder's regular New York State employees only. If said policy is cancelled, or changed prior to the expiration date indicated above, in such a manner as to affect this certificate, written notice of such cancellation will be given to the certificate holder above. Notice by regular mail so addressed shall be sufficiant compliance with this provision. No liability is assumed in the event of failure to give such notice. NY Transportation Workers' Compensation Trust Administrator, First Cardinal Corporation 10 British American Blvd. Latham NY 12110-1415 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE`C~T4ERAGL~` ~t 1 a. Legal Name and address of Insured (Use street address only) 1~ry~ ~ i LWJC lb. Business Telephone Number of Insured Meenan Oil Co., L.P. `"~'OEAYI~R'S 845-452-2600 ''";' ~~E DBA Effron Fuel Oil Co. ,a-~~ ~ la NYS Unemployment Insurance°Em~ldyerRegts~trati~on ~ ~' 6900 Jericho Turnpike Number of Insured Suite 310 Syosset, NY 11791 83-11425 Work Location of Insured (Only required jcoverage is specifically ld. Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e. a Wrap-Up Policy) 11-3083408 All Workplaces inthe State of New York 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Ilolder) U. S . Fire Insurance Company 3b. Policy Number of entity listed in box "la": Town of Wappinger 406-005407-1 20 Middlebush Road Wappingers Falls, NY 12590 3c. Policy effective period: 02/01/02 to 02/01/03 3d. The Proprietor, Partners or Executive Officers are: ® included. (Only check box if al] partners/officers included) 0 all excluded or certain partners/officers excluded. 3e. Demolition is: (Definition of Demolition on Reverse) included. 0 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. 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 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 a maximum of one year after this form is approved by the insurance carrier or its licensed agent. 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 holerr, 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: Joseph A. Grillo (#725791)Weekes & Callaway, Inc. me ~; authorized rep~ser~tative or licensed agent of insurance carrier) Approved by: 05/16/02 (Date) Title: Senior Vice President Telephone Number of authorized representative or licensed agent of insurance carrier: (5 61) 2 7 8 - 0 4 4 8 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 (9-01) STATE OF NEW YORK WORKERS' COMPENSATION BOARD NOTICE OF COMPLIANCE DISABILITY BENEFITS LAW TO EMPLOYEES 1. If you are unable to work because of an illness or injury not work-related, you may be entitled to receive weekly benefits from your employer, or his or her insurance company, or from the Special Fund for Disability Benefits. 2. To claim benefits you must file a claim form.within 30 days from the first date of r~our disability. but in no event more than 26 weeks from such date. 3. Use one of the following claim forms: -If, when your disability begins, you are employed or are unemployed for four weeks or less, use WHITE claim form (Form DB-450), which you may obtain from your employer, his or her insurance carrier, your health provider or any office of the Workers' Compensation Board, and send it to your employer or the insurance carrier named below. -If, when your disability begins, you have been unemployed more than four weeks, use the GREEN claim form (Form DB-300}, which you may obtain from any Unemployment Insurance Office, your health provider, or any office of the Workers' Compensation Board. Send completed claim form to the Workers' Compensation Board, Disability Benefits Bureau, Albany, New York 12241. IMPORTANT: Before filing your claim, your health provider must complete the "Health Care Provider's Statement' on the claim form, showing your period of disability. 4. You are entitled to be treated by any physician,chiropractor, dentist, nurse-midwife, podiatrist or psychologist of your choice. However, unlike workers' compensation, your medical bills will not be paid unless your employer and/or union provide for the payment of such bills under a Disability Benefits Plan or Agreement. 5. If you are ill or injured during the time you are receiving Unemployment Insurance Benefits, file a claim for Disability Benefits as soon as you sustain the injury or illness, by following the instructions outlined above. 6. If you are out of work in excess of seven days, your employer is required to send you a Disability Benefits Statement of Rights (Form DB-271). 7, Other information about Disability Benefits may be obtained by writing or calling the nearest Workers' Compensation Board Office. WORKERS' COMPENSATION BOARD OFFICES ESTADO DE NUEVA YORK JUNTA DE COMPENSACION OBRERA AVISO DE CUMPLIMIENTO LEY DE BENEFICIOS POR INCAPACIDAD A LOS EMPLEADOS 1. Si usted no puede trabajar debido a enfermedad o lesion no relacionada con el trabajo, podria tener derecho a recibir beneficios semenales de su patron ode la comparia de seguros. de el/ells o del Fondo Especial para Beneficios por Incapacidad. 2. Para reclamar beneficios usted debe resentar una forma de rec amacion en ro a las a s Ir e a rimers ec a e su Inca acl a pero en ningun taro mas a semanas e Ic a ec a. 3. Use una de las siguientes. formas de reclamacion -Si, cuando comience su incapacidad usted esta empleado 0 ha estado desempleado por cuatro semanas o menos use la forma de reclamacion BLANCA (form DB-450), la cual puede obtener de su patron o de la compania de seguros de el/ells, ode su pproveedor de cuidados de salud o been de cualquier oficina de la Junta de Compensation O~rera, y enviela a su patron o a la compania de seguros nombreda abajo. -SI cuando comience su incapacidad, usted ha estado desempleado mas de cuatro semanas, use la forma de reclamacion VERDE form DB 300), la cual puede obtener en cualquier Oficina de eguro de.Desempleo,.de su proveedor de salud, o bien de cualquier oficina de la Junta de Comppensation Obrera. Envie la forma de reclamacion, debidamente terminada, a Workers' Compensation Board, Disabilittyy Benefits Bureau, Albany, New York 12241. IMPORTANTE: Antes de presentat usted su reclamacion, es necesario que su roveedor de salud compete la declaration del medico. ('Heal>Ph Care Provider's Statement') en la forma de relamacion indicando el periodo de su incapacidad. 4. Usted tiene cjerecho a ser tratado por cualquier .medico, quiroppractico, dentists, enfermera-partera, podiatra o psicologo que usted el~a: Pero, contrario a la compensation obrera, sus cuentas medicas no reran pagadas a menos que su patron y/o Union hags el pa o de tales cuentas medicas bajo un Plan o Convenio de Beneficios por Incapacidad. 5. Si estuviera usted enfermo o lesionado durante el tiempo que este recibiendo beneficios del Seguro de Desempleo, presente una reclamacion para Beneficios por Incapacldad, siguiendo las instrucciones arriba descritas, tan pronto como sufra la lesion o la enfermedad. 6. Si usted esta desemple8do por mar de siete dias, su patron esta obligado a enviarle la Declaration de Derechos de Beneficios por Incapacidad (Form DB-271.). 7. Otras informaciones relativas a Beneficios por Incapacidad pueden obtenerse escribiendo o Ilamando a la oficina mas cercana de la Junta de Compensation Obrera. Albany, 12241 - 100 Broadway-Menands- (518) 4746681 Binghamton, 13901 -State Office Bldg.-44 Hawley St.- (607) 721-8353 ~ ~ ~ ~ ~. Buffalo, 14203 -State Office Bldg. -125 Main St. - (716) 847-3178 /~-,~"~`~ ~ si~'C Hempstead, 11550 - 175 Fulton Avenue - (516) 560.7745 New York City, 11248-0005 -180 Livingston St.- Brooklyn - (718) 802-6964 Robert R. Snashall Rochester, 14614 -130 Maln Street West - (716) 238-8300 Chairman (Presidente) Syracuse, 13202 -State Office Bldg :333 E. Washington St: (315) 428-4465 The undersigned employer is in compliance with the provisions of the Disability Benefds Law (EI patron abajo firmante esta en conformidad con las disposiciones de la lay de Beneficios por Incapacidad). Disability Benefds, when due, will tie paid by (Los Beneficios por Incapacidad, cuando debidos, seran pagados por): MetLjfe 1-800-243-8786 ~ The benefits provided are (Los beneficios provistos son) P.O. Box 1057 Policy No % Statutory. Under a Plan or Agreement 100735 (Estatutanos) (Bajo un Plan o Convenio) Glastonbury, CT 06037 Classier) of employees covered (Clase(s) de empleados amparados) Effecti~ All employees except for Local 553 (EnVigc Effective: l2/1/98 to cancel - Policy tv,. Name of employer (Nombre del Patron) (Poiiza No. MEENAN OIL COMPANY . L . P . THE WORKERS' COMPENSATION BOARD EMPLOYEES AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. BY LA JUNTA OE COMPENSACION OBRERA EMPLEA Y SIRVE A PERSONAS INCAPACITADAS SIN DISCRIMINAR. D B-120 (2'97 ~ Greoeribed by CMir Workers' Compemedon Board Stets of New York THIS NOTICE MUST BE POSTED CONSPICUOUSLY IN AND ABOUT THE EMPLOYER'S PLACE OR PLACES OF BUSINESS. NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8~8-997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE KEEVILY SPERO-WHITELAW INC 550 MAMARONECK AVENUE HARRISON NEW YORK 10528 :~:~:~Rl_R1f}E3:~CC311~RED:~f3Y>?HIS: CEt~TIF:FGATf~:~:~>:~:~:~>:~:~: :::::~1:f.~:Q11:>99~:TO::~:fffl#:~~2fl03:~::~:::~:~:::::::::: POLICYHOLDER HUDSON VALLEY ELECTRICAL CONSTRUCTION & MAINTENANCE INC 523 SOUTH ROAD MILTON NY 12547 POLICY NUMBER G 1038 349-5 DATE 8/01/2002 CERTIFICATE NUMBER 506-394 CERTIFICATE HOLDER TOWN OF WAPPINGERS RE:WAPPINGER WTR IMPRV ~~99-1E 20 MIDDLEBUSH ROAD WAPPINGERS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1038 349-5 UNTIL 11/01/2003 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 11/01/2003 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. REC ENV ED OCT 1 1 2002 TOWN CLERK U-26.3 THE STATE INSURANCE FUND .tMC~/~l , lam, a~~:~~%C. DIRECTOR, INSURANCE FUND UNDERWRITING 18900 CERT02-2/2001 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF PARTICIPATION IN WORKERS' COMPENSATION r_uni1P CF.i.F_iNCTTRANCF. .~._~, ., 1a. Legal Name and Address of Business Participating in Group 1d. Business Telephone Number of Business referenced in box "1 a" Self- Insurance (Use Street Address Only) 845-221-9412 Metzger Const Corp & Glenn P 1e. NYS Unemployment Insurance Employer Registration Number of Metzger, dba Metzger Construct Business referenced in box "1 a" 190 Hillside Lake Rd Wappingers Falls, NY 12590 1b. Effective Date of Membership in the Group 07/15/02 2090579 1c. The Proprietor, Partners or Executive Officers are: 1f. Federal Employer Identification Number of Business " " 1 a referenced in Box x0 included. (Only check box if all partners/officer included) 0 all excluded or certain partners/officers excluded 161526018 2. Name and address of the Entity Requesting Proof of 3. Name and address of Group Self-Insurer Coverage (Entity Being Listed as Certificate Holder) Town of Wappingers Elite Contractors Trust of New York Town Hall, Middlebush Road 112 Delafield Street Wappingers Falls, NY 12590 Poughkeepsie, NY 12601 This certifies that the business referenced above in box "la" is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law as a participating member of the Group Self-Insurer listed above in box " 3" and participation in such group self-insurance is still in force. The Group Self-Insurer's Administrator will send this Certificate of Participation to the entity listed above as the certificate holder in box " 2". The Group Self-Insurer's Administrator will notify the above certificate holder within 10 days IF the membership of the participant listed in box "la" is terminated. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for a maximum of one year from the date certified by the group self-insurer. If this certificate is no longer valid according to the above guidelines and the business referenced in box "la"continues to be named on a permit, license or contract issued by the certificate holder, the business must provide the certificate holder either with a new certificate or other authorized proof 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 of the Group Self-Insurer referenced above and that the business referenced in box "1 a" has the coverage as depicted on this form. Certified by: Certified by: Title: Authorized Re resentative Telephone: 845 -454-0800 GSI-105.2 (2-02) 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 of 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 statue 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. Please Note: This Certificate is valid only valid only for a maximum of one year after this form is approved by the authorized representative of the Group Self-Insurer. At the expiration of that date, if the business continues to be named on a permit, license or contract issued by the above government entity, the business must provide that government entity with a new Certificate. The business must also provide a new Certificate upon notice of cancellation or change in status of such participation in group self-insurance. GSI-105.2 (2-02) Reverse NEW YORK STATE INSURANCE FUND 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 1-888-997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE NIEDRA INC T/A AROMA OSTERIA 114 OLD POST ROAD WAPPINGERS FALLS NY 12590 PERIOD COVERED BY THIS CERTIFICATE 9/30/2001 TO 9/30/2002 POLICY NUMBER G 1281 605-4 DATE 8/20/2002 CERTIFICATE NUMBS 277-403 POLICYHOLDER CERTIFICATE HOLDER NIEDRA INC T/A THE TOWN OF WAPPINGER AROMA OSTERIA 20 MIDDLEBUSH ROAD 114 OLD POST ROAD WAPPINGER FALLS NY 12590 WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY NO. 1281 605-4 UNTIL 9/30/2002 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 9/30/2002 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THE STATE INSURANCE FUND U-26.3 ABC DIRECTOR, INSURANCE FUND UNDERWRITING NEW YORK STATE INSURANCE FUND 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 1-888-997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE NIEDRA INC T/A AROMA OSTERIA 114 OLD POST ROAD WAPPINGERS FALLS NY 12590 PERIOD COVERED BY THIS CERTIFICATE 9/30/2002 TO 9/30/2003 POLICY NUMBER G 1281 605-4 DATE 8/20/2002 CERTIFICATE NUMBE 277-164 POLICYHOLDER CERTIFICATE HOLDER NIEDRA INC T/A THE TOWN OF WAPPINGER AROMA OSTERIA 20 MIDDLEBUSH ROAD 114 OLD POST ROAD WAPPINGER FALLS NY 12590 WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY NO. 1281 605-4 UNTIL 9/30/2003 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 9/30/2003 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 STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THE STATE INSURANCE FUND U-26.3 ABC DIRECTOR, INSURANCE FUND UNDERWRITING moot STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF PARTICIPATION IN WORKER'S COMPENSATLON GROUP SELF-INSURANCE 1 a. Legal Name and Address of Business Participating in 1 d. Business Telephone Number of Business References in box Group Self-Insurance (Use Street Address Only) "la." Stilsinb Electric Inc. 518-4G3-4451 555-557 South St. Rensselaer,NY 12144 Effective Date of Membership in the Group lb le. NYS Unemployment Insurance Employer Registration . 10/O1/O1 Number of Business referenced in box "1.a" VIER#17-12789 1 c. The Proprietor, Partners or Executive Officers are 1 f Federal Employer Identification Number of Business " included (Only checkbox if all partners/officers included) X Referenced in box "la. _ all excluded or certain partnerslofficers excluded 14-1431598 2. Name and Address of the Entity Requesting Proof of 3. Name and Address of Group Self-Insurer Coverage (Entity Being Listed as Certificate Holder) Town of Wappinger Associated Builders & Middlebush Road Contractors CompensationTrust Wappinger, NY 12590 6315 Fly Road East S acuse,NY 13057 This certifies that the business referenced above in box "1 a." is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law as a participating member of the Group Self- Insurer listed above in box " 3" and participation in such group self-insurance is still in force. The Group Self- Insurer's Administrator will send this Certificate of Participation to the entity listed above as the certificate holder in box " 2". The Group Self- Insurer's Administrator will notify the above certificate holder within 10 days IF the membership of the participant listed in box "la." is terminated. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for a maximum of one year from the date certified by the group self-insurer. If this certificate is no loner valid according to the above guidelines and the business references in box "1 a. " continue to be named on a permit, license or contract issued by the certificate holder, the business must provide the certificate holder either with a new certificate or other authorized proof 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 of the Group Self-Insurer referenced above and that the business referenced in box "1a:' has the coverage as depicted on this form. Certified b}-- Certified b~ Title: f~lephone #: 515-371-2111 - STATE OF NEW YORK THE WORKERS' COMPENSATION BOARD WORKERS' COMPENSATION BOARD EMPLOYS ANO seRVES PEOrLE WITH DISABILITIES WITHOUT DISCRIMINATION EMPLOYER'S APPLICATION FOR CERTIFICATE OF COMPLIANCE WITH DISABILITY BENEFITS LAW INSTRUCTIONS TO EMPLOYER: Complete PART 1 ONLY and have your Disability Benefits Insurance Carrier complete PART 2. I DAOT ~ • ^•- • •• r v n~ ~.vmr~tr to tslf tMl'WYER EMPLOYER'S NAME AND ADDRESS (Home or Main Office) LOCATION OF OPERATIONS StilsinS F,lectric, Inc. Town of Wappinger Falls NY PO Rnx 27 Rensselaer NY 12144 NAME UNDER WHICH DUSINESS IS CONDl1CTED, IF DIFFERENT FROM ABOVE OPERATIONS TO BEGIN ON OR ABOUT: 5/29/03 DISABILITY BENEFITS CARRIER (If more than one, list all) NYS UNEMPLOYMENT INSURANCE EMPLOYER'S ~ N rrSr RehablhtattOn IIISUCatlCe REGISTRATION NUMBER ~ t ~~ ~- i s ~~ 8q _ Application is hereby made to the CARRIER for a Certificate of Compliance with the Disability Benefits Law. Date Signed _ 5/29/03 gy (Signature ofOwner, Partner, o uthorized Officer) Tel No. _ S18-463-4451 Title ~Y~ PART 2. TO BE COMPLETED BY DISABILITY BENEFITS CARRIER CERTIFICATE OF COMPLIANCE WITH DISABILITY BENEFITS LAW This is to certify that the above-named employer is insured with First Rehabilitation Insurance and that the policy covers: (IVaroeofcanier) *a, X ALL of the EMPLOYER'S employees eligible under the New York Disability Benefits Law . *p. [~ ONLY the following classes of the EMPLOYER'S employees: Date Signed 5/29/03 gy (SJgnature of Car 's~~typp a alive) T01 N0. 518-244-4245 Title President/CEO * IMPORTANT: If BOX "a" is CHECKED, this certificate is COMPLETE. Mail it directly to the employer. If BOX "b" 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, Disability Benefits Bureau, 100 Broadway Menands Albany NY 12241-0005. PART 3 TO BE COMPLETED BY WORKERS' COMPENSATION BOARD (Only if Box "b" of Part II has been checked) State of New York WORKERS' COMPENSATION BOARD There is on file with the Workers' Compensation Board, Certificate of Insurance indicating that the above-named employer has complied with the Disability Benefits Law with respect to all of his/her employees. AISABiLI'I'Y BENEFITS BUREAU Date Signed gy Telephone No. Title DB - 120.1 (4-99) LETTER OF TRANSMITTAL STILSING ELECTRIC, INC. NYS CERTIFIED D/WBE TOWN OF WAPPINGER Middlebush Road Wappinger, NY 12590 Re: Robinson Lane Park We are sending: Signed Contracts Insurance Certificates Perf & Payment Bonds Descriation Building Permit Application Copies Date No. Descri tion FOR YOUR APPROVAL FOR YOUR USE FOR YOUR REVIEW FOR YOUR COMMENTS FOR YOUR SIGNATURE FOR YOUR APPROVED AS NOTED APPROVED AS SUBMITTED APPROVED AS CHANGED REJECTED AS NOTED REJECTED AS CHANGED RETURNED FOR CORRECTIONS RESUBMIT COPIES FOR APPROVAL SUBMIT COPIES FOR DISTRIBUTION RENEW COPIES FOR Notes Received B : Signature Kathy Stilsing Print Name: Title President Date 555 South Street, P.O. Box 27, Rensselaer, N.Y. 12144 Phone: 518/463-4451 Fax: 518/463-7023 MRY-29-2003 THU 09;09 AM WAPP,TOWN-CLERK 8452981478 P. 03 TOWN OF VNAPPINGER BUILDING QEPARTMENT PHOI~: (845) 297-6256 FA.X; (845) 298-1478 APPLICATION FOR BUILDING PERMIT APPL CATION TYPE: [ ]RESIDENTIAL ZONE: [ ]COMMERCIAL APPLICATION #__ [ ]MULTIPLE DWELLING PERMIT # >APP ICANT/NAME : (PERSON PHYSICALLY COMING INTO APPLYj: ~ ?N, bc~nBl ~I,In'l~~t~C , I~(! ADDRESS OF JOB' SITE: ~ ~.~ TELEPHONE NUMBER: _SI~ ~3--yy~I )'C LS >OWNER OF BUILDING/LAND: NAME: MAILING ADDRESS; TELEPHONE NUMBER: COMPANY/NAME: ~-! • ~' ~~~ ADDRESS:.r~~S~_~~u1~G~ ~~ 11~l~ CONTACT PERSON/NAME: ... SETBACK„; lv )~0~~ SIZE OF STRUCTURE:. C ESTIMATED COST: GRID # ~ ~ ~ - DATE RECEIVED: FEE PAID ON: -- ( ~ ~) ~ r cSf ~ TITLE: T"I~ I. C.'zT ~~ ~ ~ . ~, D TYPE OF STRUCTURE: _ -- - TYPE OF USE: ESTIMATED VALUE: » PERMIT FEE:, CHECK # RECEIPT # ~ 'elm SIGNATUt2E OF APPLICANT **11= JOB NEEpS ENGINEERING raLANS OR COSTS $20,000 OR GREATER. 2_SETS O~ ARCHITECT-STAMPED PLANS ARE REQUIRIMD** Associated Builders & Contractors CompensationTrust Attachment To Certificate of Participation in Workers' Compensation Group Self-Insurance Name & Address of Business Participating in Group Self-Insurance Stilsing Electric Inc. 555-557 South St. Rensselaer,NY 12144 Description of Operations/Locations: Job #310- Robinson Lane Park - Wa in er Policy Number: W333256 Workers' Com ensation Limits: Statuto Employers Liability Limit: Each Accident: $100,000 Disease Policy Limit: $500,000 Disease-Each Em to ee $100,000 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF PARTICIPATION IN WORKERS' COMPENSATION GROUP SELF-INSURANCE la Legal Name mad Address of Business Participating in Group ld. Business Tale hone Number of Business referenced in box "ta" . Self-Insurance (Use Street Address Only) $45-297-4734 Chris-Bar Electric. Inc. PO Box 506 Fishkill. New York 12524 le. NYS Unemployment Insurance Employer Registration Number of Business referenced in box "la" 10/01 /01 lb. Effective Date of Membership in the Group Certificate Period: 01101 /03 To 01 /01 /04 07-135292 Certificate Number: 0000827-2002-0000041-0 tc. The Proprietor, Partners or Executive Officers are lf. Federal Empbyer Identifieation Number of Business referenced in '~i included (only check box if all partnerslotYicers included) Box "la" [j eU ezcluded or certain partners/ofllcers excluded 14-1543363 i 2. Name and Address of the Entity Requesting Proof of Coverage (Entity 3. Name sad Address of Group Self-losurer Being Listed as Certificate Holder) THE ELEC-CON TRUST Town of Wappinger 10 British American Blvd 20 Middle Bushroad . Waopinaers Falls. NY 12590 Latham, NY 12110 This certifies that the business referenced above in box "1 a" is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law as a participating member of the Group Self-Insurer listed above in box "3" and participation in such group self-insurance is still in force. The Group Self-Insurer's Administrator will send this Certificate of Participation to the entity listed above as the certificate holder in box " 2". The Group Self-Insurer's Administrator will notify the above certificate holder within 10 days IF the membership of the participant listed in box "1 a" is terminated. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for a maximum of ane year from the date certified by the group self-insurer.•• If this certificate is no longer valid according to ttie above guidelines and the business referenced in box "I a" continues to be named on a permit, license ar contract issued by the certificate holder, the business must provide the certificate holder either with a new certificate or other authorized proof 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 of the Group Self-Insurer referenced above and that the business referenced in box "1a" has the coverage as depicted on this farm. Certified by: Certified by: Jane Falconer (Print name of suthoriud reprountative of the Group Se{f•Insurcr) A ._ _ . ~a r - -- - . 02/12/03 Administrator Title: 518-213-1900 Telephone Number: . GSI-105.2 (2-02) __ -_----.---------..____ _-_-__- _..------- --_ _ _------- _--- JUN-10-2003 TUE 11:59 APl WAPP,TOWN-CLERK B6flel28B~ 1is96 848~2348~= 8452981478 a4F~'rrtRY :3aLU1'ION~ PAt~ e~/91 ~~~ ~ ~ +'~/ J~ n ~?98-1 y 78 ~_~~ ~~~ 7~1~4~r ~ ~ ~~ ~f~f M11~ 1~1~1K11eN~~lw~ AM Mllr 71A I~rM Arr ~wf1 ~t~ ~ I jM1- l~ M ~~i1~Qt SIR ~~ 01~~Y Y01~ a~~"~'~na°~ '~WOR,9' {"Q11A'C1Q~T BOARD BTAiT FGx A C3~1~RNh~"Y,~{'.N!'i+~''~' x'~AT A b><TBD~¢S AQ~ YET D]CQ~,E Wd~S' CoSV~srt~l'xYOi~ Ar1A/k~it A~4-4a1'~tTX 1~l~N~Ft~"ID COV~IQE • ~OYciIMy Nast! ~ T ^' 1u~lnera arTrad~ Nina niri~.n! ~ppNeilYt'e MloAta Addraes ~~nae1 Adthsos ~fryeivd I.oQstla~, If DIR~nn-t •ioms T~rtYpltotte Nnrnar Qutlneir 7~1NP~n ~ba(, it Dllri~t nP° ~ s~aae Co~e/~~A rJio~v _ ~ frlidbrrl 1donRrf~o~tian Kumar o,~ - o a ~ 9 yi 7 f~tgr ~wq~ x r tlwe ~ ~ Worms' ~a t~e~ wa eow ~ ~ ar~+edaaew w aw ~t re ~.1tlle-~~ M~~ ^ tlhe bleu ~ awed ~ oaa io~vfi~l ~ ao eteplepap and se ta! ~ totpast'ie~ Q aye bwtoa.~e I~. p.ap.diN,~r a-. rvwe of taw Yodr siiw, and >baN etr ~,..ery+tae..r. j~ a~..w ~+rem o~ twa pema ~erpe,r~ea ~ atateWdhtdwkaV~all~ a!>b. dodo ~l~iva~ a~ tie . •sd ~ ~ po to~lti+'iwe. ~ . tllebueMa~ efos aotYVq~da dlf~@'1M41~itCENYa~y1 aide ~ ~ 4~ aac eglplord ~! Or ~ l~rid!iU,Mt weu dat feet so d~a iaa~47~'• , Q ~ ~4 atNoc ~rawvp) ~ aptes~ eagplee+}ptv~l~~roskte'Roetttp~aewtetr+md 4Ne~l~bna~rvoreu~~+1M aiaw u ' ea. ea tlwrt s~ ~,.~~•..~~~ ~. 0 ~~ ri. ~ ~J~wrM~~~ - wri 1Vbtae DA~asc '~r° ~- `~: ~//"'~ 0 ..1~" ~.i~rw..n~.~.rrrM....~.. JiY FAL,A~ SrA7~lABNT~ ItiTA410N, OR CCI.M~VYILI. iNBJECI' Y~Ot1 Tt31~l.ONM ~INMgrll{~ x~iol~ ado ~~~ ~. ~~n~r ~ ~ooa wm~f~v~ol~b~ e~oarn~ u-w ' rr~tt laa~aa 69 ~ . a ~ larw b~bed en tie I~iraoinq o~lllo~en ~, ~ bpi ~ abaw Auslh~.llM iNbtloN! o~tlMpretbaUba Beall M~ ee ad)ealbnM, al lilt Itittl. iii 1hQ flMNnoe ~lrlp~INW~d 1!e pt oellk~W. ' ' i ~~r ~~ e ~~~ ~hon• Fa~rak: ~l~ v3~g ~ ~ ZYdd: o?Ut,rac arm Yse N~ 1'!~p A! to M1~d Ottlp/ t1'~m /D~ ~ ~~ ( Rear iltbfMttNn1~ At flM !f~ ai[>~ tattn, NIIM bfrkN^o aral'Nlaitai io be tlllm an a 0 pr aor~lrid by tt'9a'Mw~itltlbM . ~ ~ nwuc p~gr(ga ttt~t ~ahrNnaa +~ s now a~sarn^fK, ~- ,maw >* ~+ etarpnaa~ ~ r1o~' oongo+ins~sn..rNl Dbeupplgf 9eewtM~s oAVars~ be tltr gw•enahw+tale~y K eks~ ~~ s° • b~, e ro r.gdU.ry aaitd~ lhin vied. mow, tt Ia wrai•lvea ~ fno Ilonrd t+oiNv~ 1Aa dg~m rpw~t tc~iott~ ~ p~rmu at ova K. aii~ ewalfgrpan~ ~ k tbttnd tMtt 1~ anew burlttwtr Is ngtdrndio hw• oWnm+n' ti at~dlenb~t botlrAta ov+-eragr. a~~~ er9N• 1.~a rsa ~aeai•~.ein •~n ~,~ ~~:ra s~++~-a~-Nnr Ig ~ l 3~-~' r . .,~, - -~ P. O1 T00 ~ ~O1~11SHI ON 6099 bLb 9TS %i+d CT ~ LT ~17.L CO/OT/90 12/12/03 FRI 04:36 FAX 4tORKERS COMP DEC~• 12-2003 :34 P FRS 03 M WA TOWN-CL>•:KK P P . ay4o~oo 14 r n 0 ~ 0 2 . ~ 11 , J~,,/ I ~ F y /~ {I~ s B y J~f`, I /y/ pY- / " rm wcs IGDWa~ltal Noe wa- rata was Y1CplgVfol ~DAfa7r1a1 wrA.tfata Nos war 107 Wp~p~ip~vfef WOS X01 was fONltlf etE W tY~l vs wc's 1o6'W~ 47 bbtfi w 1 01a J1v~. NYiwd~ Mlodtpat NY'1W06 o tirod.ry S asst. olpry 111 l.ARnpol~+ pW~ oN~ ti ~ ~~ 476 FWbl1 A . eC Wd FMPr DMUa+ 7t. Pf~l~tl flyd Pion ' Auf~s /sOlArln EI. l~q~C7{~ _ ~ .M~ ALB fagot k Nw~oy bo..l oald I~udr PM9Weti0N aR001Cl.YN sUFF~LO EuM 1DO 1~e HA1,1prAU0t: 1f7aP Qtt vw Fi1r1P91'yD tltlo Itt:W1M1lltlt 1DOR7 1~ af8a174b~ 1tY8. ti4Y18Tf"' 1~~f 1~~ I880d-Bo I (p8A)76a sts7 fEe01 117at f~ eoaseo+ Iraol ell-t879 • t !ate ept•gN ` 1 (BiBI POI~aeD ~ a l ~ anal a7>`•1r7o ~ ~ oeaa fo i ) fsi79 Feats Tier} ~ ~ OA 1 ,m. ~ ~Sb'1-) Fatel!~1 t*~CnU ~awl(~ 1 Fi~~tel 1 s eon i e i a 1s•9t ii 7p ~ -- Affidavit For New York Enti~ps And Any but fit' State Entities With No Employees, i afar rvew T vrR State Workers' Compensation And/or Disability Benefits insurf~ncfa Coverage Is N©t Requirod (~+eorwJrlete fors tofYibo reA~rded-pteaae ca~ef err aserAp V,~ dare ~ v+~s+' r~ ~'~:1 voThia form cannot be used m waive tl~a worker!' aat74ptruatio>t ri8lts or oblTBatlot:r q f srcy party ~nclt~r+g a rr~bcahdnietor*" The. applieaint rt+sy use this A{~idavit 9-,~C to show a ~ovesrataent oadty that New York Statz specifk wor>a~s' cotapettsation and/or disability taeaei'its•irtsttranee is ant ra~tiira'd The applicant mR9 NOT uoe this form to show oil~ter other b1181GRSRes or those bu3i»eae' ittanupt-oe cetrlers Cht<t sash ia9W>tace is not roquired. Applicant mast tsitlaer Ysst or tatail this completed form to t~tb closest Ne1r' York Btatc Worke;,b' t;otttpeust-ffoo Hamel ot>riox ark the Glac tntmttsr or ate wed ors the top of this iorm. i*oo looms ~riIl be mtucn~. Pimoe Hate: Tb:e etetets~eat M17/Pt be- uafaeixsd and also lta<re beets t~ by the New Yorlt 6tate tYVorbesr' Coagpabttattott $oatd. 'i'lsia a!lldsvit .oils not be acoeptad b~ governmetxt o~ials>: btfo 9~ JStoliq~ t~ date reodveti b9 titer R-orkocs' Campbosstlon 8aotrd• U'poq receipt of s RrDy eotnp]eWd WCJDB 100 loan. the Wvricera' Conspm.pdon Buae'd will :temp rbis !oral sis tessivad att-d ~ it !lam which y~orJ met] or ~atc. plena. psravide a copy (or the aaiglnal, ff taiult~ed by the gof~rsttttrsnt altit» o! this aacatnpsd lbrm s9v fiw aoventtpsRlt tY arc requeatiog a petlnit, ltoatue or coniracC ~ . In the ~¢7 u S9 , o~ es8~, C~[?O. t'siit) l~t'~>~~1~~, mil, ,~ ..~ far a ~*''~iaetue/cotw4ot slats of `~''' ) county oaf ) fl trlT.k~+r~~ Sw/l.~.ly _ - - pyppp,~'a naiwa) tieing dWy sworn, dspossa.od says: ~~,~.~ . 1. I em cite, _ (Palttton) adtit . 'd. *`~'~~i•~d~"G~r~~) asr or made ~), a /2.c:; 7a•~'!FrP ,. (eyps of bxs~xevs). The aelephoAS nuwberr of tba 5~e-aass is d - 9 ~ 7,lta Federal Etxtployosr xdenafuA6on ~+itranbar of the businasa (or the Sovlal savualty Numb' of tba bttsineae owaac) i8 -~`~j'~~ .The New Ytu'k Sterns Utwmployment Ynsarancts Stnpla~r Regls>mtion Nnml»r (if say) of the business is .~ I ~tm that due to my pgsitlofl with the above~t~utated busimies Yhave the know ,iot'ormstivn aid authority m make this afFdavit. ~~~~- Address is irs.o f-n.G~ /b-+'~ ~>pd( itgy horns talFPhopO nt~abaa~ is ~. ~. ~ . l~/aa.r4 /~>/T a o-a~r/ l~~selco~~ 3. 'fiat t'be above aerated business is applying ~' s (txp ~ P QPPh'~Bfarl from _ '?~N ate" l,~i~N ... -, (gove7nntertral a-ltlry lerutng f~ per»sirl t~a++avrontroct). 3a) j0 tlodai -- >rocat3ott of whRre work Haiti be pufidit>~ed in 1~Tow Rork Stpto /y1~Grwd~Y G~,/ry' ?~r.+~/~ s+~~~ from ___•_r..,^ l~ teecessary .~ r~ .~ tv complete work as~roCiatdd with permit/Ticdn~/ao--tsacl~ The estimated dollar amoua-t of projt:ss't is 4, That tfte above ~d busineaa is cattii~{tt8 sisal rt is taa~pt tkom obtaipit-g Nea- York Sfarte spocii'~t: workecp~ CQmP°m~°n inem'encs eove~rAxa tot rite following teas9on (W be eliMiblo for exetaptioa, epplioattf.~utuat be able to p(nehfuily check fall o!'the boxas ftotri era. tiaongh 4h.). ~ to ~. lased 4a.) the business is owned by erne ittdividtul and is not a corporuian. Other t>+at1 the owner, tl>ec+e are no erpp Y employeef;, botaowrd ealpluyees, ptlr;k•time oaoploygsa, auhooatraat~otg or unpaid WlnsteeRS (inosludittg y ttwcabec's)• 4b.) the lfttsiaea8 is a pttctt-atthip uttdae the locus osf Ne~v 'York 9ta~ and le not •a notporatlou. Otltea' t1>e~ the Pm'~+ the area no enlployaes, ltu+eod eugployasa. bofsvwod ~patployeas,, paro•citac tmplvyaea, sttbconttttctaes or unpaid rrolttittear6 (lnalading ~mflY members). (,ifu# attar.!! aepereee s1+~t wt3lh a lire qJ' aftt lie ppr*nw traeata' add oa[t'o tdib else ~rs'saret of all rJlw,pgv~tnert.) 4e.) the business is a olio perenn owned OotQoradOa, a+it~ that lodividtral awning' all oi= the atot:k and holding all t~~ of ~1° earporatlom Ocher than else corporate owtwe, dtste era no ettaployeea Iated employesc, ba:roa-ed employees. p?art.tiime employaos, . aubooritractora m pnpald volantt~ (t>uhuling fttfatlly mea-bere). . J ~-`~ WC/DA 104 (12/03) {Replacer: C~I05.21 Form} ~ (Over) 12/12/03 FRI 04:41 FA% WORKERS COMP. DEC-12-2003 FRI 43.35 PM WAPf', 'rowH--cl.irKK G40GaC! a ~o , , „~ ~ 003 b~ 4d.) the busieets is a !wo parson ov~rbed eotpwraAOn, wltb~ those indfvldt~sls owering ell of the croak and holding aU oPPlaas of tb~e' corporadon (eeoh lndividusl Haut own at least oqe ®hate of stoalc). Other that+ the corporate owners, there are no eenanployeeec, leased employees, b4trowed autployeea, peertrtirtte etnployaes, euboontraeeora ar unpaid volunteers (including family rmenobera)• (M-we ooeaclr sapevae• sb~d tv~rh a hidr vl flea rams et/'botle owAa+r, Bind r:tav tottA berf/i ow~'r' det.) ^ rio.) the applicant ie a nonprofit entity (undar IIiS rake). With tha axeeptfon of clerBY or teuhera, the nonprofit has no cen4penaated individuals or subcontractors pwvidiag any services. • ^ af.) the busiaeas is a farm with leas than $1.200 in payroll the preceding calendar Y~• ^ 4g.) the a}~pliosnt is a hottitowtteu .serving as the , genattl contractor for hir,/herr primary/aecotsdary y~araonal tesxdanCe. 0.~ ut-componsatt;d friendsKamily are belpit-g m build chic sttvctu:!• , dh.) other than the bu8ineae oWa~(s) and ittdividttelc obtained ~ a regiasoeared talnporasY setwice agettey, thrx• are no emptoyeas, laaaed ernployeCa. borrowed arnplayeea; Para-tuq~a arttp]oYe~, BttbcoatractoKs or vnpatd voluateear (tacludit-g fanuly tnsYabers)- Other then the btuinrss owner(s), al! individuals providing 9orvicas. to die buciaess am abtainad ~roa- a regieberet) ternp~ery service ~eney ar~d that agency hoe covered these indlvidunla for >!Tew York State worktzrs' eamprattaatlott im>yrancr. In addition, the business u owned 1by on. individual eu is a partnership under the laws of New York 3tata Had is not a aorporadon; ar is a one or two p~reon owned corporation. with those individuals owning ell of the stock and bolding al] oiftcas of the caurporation 5. I'itiat the above named f»tsiness ie cartifyitig that It is ex+ampt from obtaining New 'Y'or1c. State disability beaebirrt& instrrat+ce coverage fai rite £ollowins t+eaeoa (m be eligibly for exmptton, applicant must be able W authfitlly check Old of ttta boxes from 5s, through 5! ):. ^ 5a.) tttr basinesa M owned by one ineiivldual or is a partgatt;]tip under the liar of New Yock State and i• not a corporation; ar la a ens or two ~erean owned ce~poradan, with those lndividu;L casing all of the stock sad holding aA offices of t4a- aorporatiwi. In addition, the bnssaesa does not requite dieab~ty bene~a aovat:a8e at ~ time s~CO ~ ~ not employed one or rstore individuals oft at least 30 days in any Calendar year fin New Xt+rlt State. (1>f~ne%nt conrrne~torx ew's Hat eonrldearad m be arjployeea order the D~+e:biltty• Behe~itsXatv.) . ^ Sb.) the applicant is a polidasl Rubdivision that is legally exoanpt tsraat-•providitt8 >arY disability btu~s covaragtr. ^ Sc.) fire applie'•ant id s nonprofit religious, eSaziCable or adt-catiooal 1»stitudoti. With the exnepdon of execudve oiFie:ezs, aLrSY~ sexton9, tegeheza Qr professiotialc, Cb6 not[prOB,t hag po eempenaatmd individuals providing services. Sd.) the buslhes6 is afstm end all amploytie6 sv'a farnilahorenrs. Sc.) pplitat-t is a homeoosnar carving as the Several ctxttractor ice his/her prir:,ery/secondary Pn*atal residence. ~ , u tn-bgsated frionds/tamily asr lsclping to build ihiq eittiotrrre. . . ~f.) other that, tba business owM#'(5) and lndia+iduaic obtained frousl ttre tatuPo~carY'°ri'i°° e~y, thens are no e~tfter e~oyeies. Other than tl~s btu;ittess awnar(s), all individuals providing 8eryiees to the business are obtained 'lkom a regletsred temporoty cerviC~ rrgencY and that saency bas covered three 9ndivldnalc for Nevi York Sty disability beee£ts instaahca, Ih addi4ott, ttre business is owned by one indi~ual or is a partaerehip ut-der the ~ws of Naw Yozk State and~is Act es e:orpotadoa; oz i:r a one eir,ttvo pet~a owned ootpotation, with those indivieiue]s ownUnli sll of tbn stook s»d hvld'1nC sA 4ffieet! e!~'the ootparadon. ~ uit9d, such ae the hiring 6. That if airctumBtancea rttange so that ararkots' ~pansstion insutsnce egdler dlaab,7t'ty benefits coverage ~I of a loyetu, the above-t~nad bwineaa will icia-ediatiely nc4ttim aPPr°Prla~ New Yp~rk Stt~tts ap~Fio worl~ra' compeon ~~°C° aqd/~ disability boereflte cvvaa+~rv esr~ also {~ediately fitrnieb proof od'that eovat?~e on fore:te approved by the CEia1r of then Workezs Co lion $oerd tb the governatent etsdty listed in item 3 on flu lrrept of tbi6 lorta. • , 7, t based oa tbu~ latra prace~, Y o~ that ttte above-natpmd buaieeas done not regpjte (cfieck box ?a. and/or 7b.): 7 kars' aompiq~aation insttcapce. (applicant ttltrst have cbeaiced ON6 e>ttbc bo~t~es frott140. through 4b•) 7b, diaablli beae~tta inawnace. (ppplicant mmt pave aheolcad ONE of the hexes from Sa, tltronain 5~) lRal~ 8. )iy si4~ing my fauns balsa, I bsraby atfi~m lbat the ,~aaauts tarede hetr1u era tree, t`hs-t I bare not tcvade latent, stastemaatt and Y malts ~ ad6davtt nadez' the peeah~ea o< pet~ary. ~ X fitetbec affirrri I uadecBtand is aeeortance with tba rapree4ntahaa pc ooaesealtnattt will atst~eet tae to i5t~>aY arinnfnal pmBeeution, ittclvdi sad civil Workers' Compadsadon Law end all eathei New Yank State laws.' - Swore bofioz+e me this ~ ay .~3 dEG i 2 2003 • 1`io Public ARtA ttllBRIOE • ~; a' • ' Notary f~'bhc to si itew'lalt .h • RS~gg.. Nc.b1~150131674 ~~yy~~ QttA!iliad in Du-e~ess CO_11,~,~ =::'.•' oa<dt~ . Compassion Esptres ou.3, . $esaaae tltit .h a avuorn sdlldav]t, emplo'yaes of tM liVorktrs' t^ogApapraa-on $oeed smueoE assist epplteao~ ie aaswettigg gt~ea sheet this infra. WGDB• Xa0 (12/03) {Replacap C-I05:x1 Pram} (0"O!') 32/i2/03 FRI 04:33 FAX ~2/12/E043 FRI 2; 56 FAX D£C-12-2003 FRI 1107 Ali WA;PP. TOWN-OLERK . -rrewe~r 771~4aMpNpa N ~tt~ woitx>rtts coMp. 8452981478 s,.~ ~ . ' ~ uu~~~ui 2 P. 01 ' Stafia WaHcore' Camperisalion MdlQr Dis~biilly Bonefits Insurance Cav~rage is Not Required ~•1°,~s+wa'br rab~~li~rlan ra~set~ mM-ev ~~!M l~n'v n~ gws~r r dl~,lb~J eM?~~ q~,ot bs eu+ad >b w~ Hie tvor~etrs'rw~pe~oa t~litar or olr~aulalir of mV,P~~ ~~8 a sabFo~' Tbt: applicant may sae tlss AfbdaV'Lt oja~Y to ahow a soverni~ist ~tlly tflat New Yank SmTa tpea9Fia. worloatt' cotitQansatiatt bndlor tiiaAbl)lty beaetll~s-~nsaraam fe mC requaM~ Tl~a appIic~wt may ~ aee chia i'o~v.to sbaw ether at~rr buateiesAea ~' t>~Muinnee" itlaWrp~cn catt~9 d~ such i9rtst~rauoe js not rquirmd. Applteatot botW! ~tlter ~ or ~ tl~ eomloletad lb~e~oa io tba doreAt >Vstr York ~~ Wor1W8' ~ Hosaed o~ea ai: !be ~x easabtt' or sd~eac 8sbad on t'JLa top a! ~~oa ibrs. use ~ew+sv~l,^ ~rned. Please note T~ m~~ be woEOU-~r! wlMt obse bavC i'a~ ~ ~d' ere IQA Tork li~fa WorlcdlP/' ~ ~parp;llis'~doodt wl0 t+aR be s..epdd 69 ao~uyt oiHeiWe oae ~ h'ass ttm dna:aedved by tb ~'or>saes' ~ ]flousd~ LTpaa seoeiyt ~ e 1Wly WCJDB ~ Oe tb~ dm Woslmss' atlas ~amd a+ill seomp dd• them u tecdvad sed rtxu~ fie m Yea by eitbrr~ tYtldl or mx. i'f~ ptblride a espy {pr die ptipipl. It oegoltod by fbe ~J ot!!ds sQestpod fiaum m the sovanmea ~q~ Ttemt wltfoi Tau acc a 7iaau~o artaaa~. ' . . O~KIi/~ L_~C. • Yn ttv A~pljoaaaa of (8uslnesp Nerve attd Address) ' ~, , ~9~. ~.~-~ Ste. N . fora ~1 ~ . chi r1 ~ _,~,~~laont~ex • Covt~cy oP . ~ .u ~ ~ S ~ ~.: „~R~Rbcv~ c/s ~ (,gppit~~a,~ar,.J bs~g duty a~ ~ ~ - 2, am fiber o .~ ~v ~,1~ (poafeletrJ ~rleh . ~ dppotast ~ (b _ ° '~ .T~F ~e1 ~~ ~~ (type of bwtkaar). ate falspha~ne stOsabet' of ew bupiaecs i< $atgibyer ?ddodpositos Nuoe'boe aE d~a b~rtses Let; Aw $~nmoq- rllurltber a~ (~ badaa~ owacr) is The New Yo~G Stale ~ $~lo~x >~tstratiom Nmmbcr (~ a0~4') of fire bttalnaas is Z 4~ . that due 1e say pocidea wub ti+e sbova-uemed bv+~ i Nava Qte lama uafojmmdion sad~p ~,yr ~c 'a~a'~a sf6d+~vlt. Z. ~ pawnil addppss ~ .73 c~. r~.~C~,e~ e[~aoN .}~crNS/~~5ad~' ms~- tote toleAhanr n 9e ~ B ~ a-a~-s/ 9 7 _ - 3. 'i~ud floe ~boya t~ bndtAM! iR o(splyfing ~-: ~ ~ (=9Pe of pstaail/ ~eense/1eos+erad aPp~Bln-) from 7 ~ «•v a~ ' r.~ ~ ..v ~_ ~ . ( ven~,~asl~ rn~ty ~ t-~! P:..Ard t~salcoarrtetl. .30) ~ jOptiortai .• LOt;~ioa of w~ wodc wm be pe~a~pd n ND'tV YocTC 9faTB ~A ~...~...~~ (mod 1i6sY.ttt~ry to ravnepiate wosk gfspal'~ed wilt perntidh'esess/~ar~'Iba aa~ited dolieti amore o~'pl+gJooc is ~o°~ o~ 1 4. Tb~ the above served businesg iC oatdfyiag d~ it i8 ~etopt !~ abtaow~ Ne9v gadc S~ 'speot6c wa~a's' ovts~s~~ tgs»tvne• eoverts~ !oe the to>aewiag =eacan (m bo ati~iblts lfeor exs~mpdop~ appticmot mast bs able io trprhft~y etteolc aP~ of tiro bm~' from 4a. ttuouXh 41s,)_ ~ ~ .. Q 4a,) tba t~siness is owned by o~ lndividnat and is sot a atnpnn6an t~0~et' than the owner, theme ars cio employo~ yenned e~ployep~ bossowad ewq,'1o7roeo. l~f ~ emPlayee~s. ttnctoes 4r uapalri volts (inoindlag fay mem6e~s). [~ 4b.) tbo bs:;sass is s pa~mea~ip a'rder dre lavef. ~ Nnw Yosfc Some sad is not p oorporaSon. Oslser tend the psi. d~ see ao eeeaplayems, leased eroployear. bouo~rcd .tmptioyee~ posvtim• eatPToyass. sobootat~epets ar aepald voluamm7s (lpolnrlit-g Y Tt16~l~. ( A~Osb repalall trxlCet IVWi R ~ ~ ~e 1Nete! mill ~o.~ ti<te f1{fAOZ~oe evagtPiey~07oe/a.) , ~4ri.) tiu basazms is a oae psesao owaed '~~ tbs¢-mdivldual owaiAg' ell of t~Ie,etxY apd bolding aI! a~o~ of this co~o1~0A •OdrOf d~ d~+ cocporaoa orv~ ti~• are eo aayployess. loaned employees, bos~w~ed•etnptayeea. p~Rttime eimpiDyes*9. snbcet-ttaetars o: unpaid vo~oteera ,f~lud'mg ~mliy xe~s~~ . .. ..... _ . ^L../Y~ ~W ti6/~+3~ {~+~,~~L'~6 ~:`iV.7.l.~FOIm';J,' :i' ~. i..t. 1. :t1~~~~ ids: ~,t.~~: +~'++. ~!rfy,~'; .:: -~.'i L••. ' .. .'} ±. 72/12/03 FRI 04:34 FAX 12/12/2003 FRI 2; 56 FAQ DEC-12-2003 FRI ii~07 H1'1 FYORRERS COMP. ICJ OOZ/~Ul 3 WApP, ?OWN-cI~ERK 9452981478 P. 02 4d.) the bttsiaetr 98 s two pe~wa orvaad easpmstio•at, wlih those ladivldaala owplaS ell of the aoaek and taoIdltu ~! a~eea oP the' oarpotatioa (eaDb 3adir-3dtgl roger oA-A ~ 1eaBt ~ shat0 of Qoc'J~J. Oder tJ~Ori ~o aot~uaw orNlaas. !~r• ~ no .mPloynex~ leased employa~ bottoWed employees, pmctiftoe employees, aobagopra~tots dr aepald volnntanra (iaaludiag mp~y ttmobeta)~ !sever auaoA ' srpasir~. aAae »ttllt a filet sf avers ~w evb~ vwsorrq, aK sbs trlpit Ilotli<iMtrrrar ~~ Q ~.) ~ appIirant 16 ~ aogp[ofit etitlty (under ~,$ 2tl1Ci). Rritb dta excaQtion of cietgy az oeaehets- the notgxa~t has tto.GDwpeartlted lndivtd~ Pr OglboOatreaLOer provid4nS any aao'vlrxs. ' 4f.) then bdaiae+se is a farm 'wtfb kss than ~ I~001a payrou the ~s•a•diaa calendar year. , ~ ~.) tbt appliwat !r a homeowner s~'ViaB sc the • gaacnl. eesteraooor ~r hi8/hat Psim~yleseoa~y parsoaa! reutdoaoe. ~ tmcotupdtlsgrad~ftiendsliaadly are helping w band t!d~ s~tnotssre. . ^ 4~.) other than the bucipase ovnter(a) a~ lodlldduav o6niasd from a ro~dtotsd aampot+aY aervlee ~,at,ey, tbafis tco no esttplelrees, leaved ctppioyxs, ~wnd •mplt:•y-est, D+~iim• oztg'loyva+. subaortt:acton on wspald volun~s (!nc)ndislg ~+,mdotbe~): other thaa the be~riaest oweteKs}, all iudivlduak laavidiaR ra v]oas m tb• booiarsas era obamed fto~ t r+sgistered y s'svioo ~Reaoy and Isar agdtfoy hss oevdtnd these iadividoaTa for Nsw Yatic ~a wosloss' eonipOt> ititiuRaao•. 2n addldoa, the bostneas !s owneII by ens iadlvidaal or ~ s aadeir trite lawn af' Nave YodC Sys sad is ao~ a eotporadon; ar is a eae- or t+Ye peaccn owned corporapon, with tlwms in slduais eweittg sU of the snick and hoidh~ all vtne•e ~ tlm tatpor•don ' 9. That the above aam•d busio>sss !d oeatil~-iaz ti-~s !t !s eetempt ~oae almddibS Nsw'lfotie.SO~ dlwbilicy besearits ia:turaneo aovsage goit ~Ilowlttg tsatoea (eo be eligible t~ s~lemp{laa, apgL'oant most be ab]a tti s~tthtYtlly cheek DNB of Ste bou~ flow S: thtauSb 5~~: Sa) tht btts(aasa la o ~ indlviduai,or ~ a parmeasb~p tafder'di0 tarors of Nave Yatlc 9txm sari !s pot a e~tpoaation; o; is a ope or tae person owaewd~x~jipot witt- shoe. u,d~vldamb owttlo~ a1lnf rho aoock sad >m)dtoj sII at'Rcea eaf dts etarpoa~lem. In Sddition, d+• bpstba6s does mot t+aqulro ddrab1~41y be f~edts eor01~ Ai !'his Ilvta ~ u hAt t-ot employed one ~ mat+e 1n0lr13dva1F oo• et key 30 dsyt 3n aay aaltadar yru is New York State. (7ae~pettdeatt eonbaretorr am -eoe eo~tldsred ro be ~+Ioyear t+sder rile Ds~•bt?1q- BendiLr IaW. J ' Sb.) du a~gEtcsnt is a political sgbdiv3sion tTtttia ]ogdly essmpt fintn•proriding awAteoiy disaMtity bena~ coverage, Q Sad t6o spplboaAt ,ia o ao>ap~atbt re+l3gbut~ obasitabd• os td~ewfjottal loalltatttoA, gVith dk aleoepdan of •*,~^•~;,ro oldoeTi. eLirgr, was. trz~e~ or pto~assionals, the aogptgist bas ao eotnpt~samd ladiVldtrala gror+iding se~orc. 5d.) the- buslaeec it 8 ~iocta sod all employees era ~ Iaboraa , 0 ~e,) the a~pyieaat 3s a homeownee seavhty +Sr t11e stalest aomK~oe for bielltar primeey/a4ooadarY P ~ . emoonopeavared friendslf6amiyr a[e )telpwg to baild flue ~„~+••• S>r) other t'haa the business oasn<(s~ sad htd~irlOtlalo obtained t~ rift a-.gtporpty setvic+e aSmtoy, rheas ms no othae' emPleY~s. Other . ' flies rile bustaem owl). all ~ividua7s pao~-idit-g sarvioea to ~ 6oas~ ace obeaited frnpn a argietrssd ortr;ptamy sasvlae a6~Y • sod t>Ae-t >~Y hat cavesrsd 9+eae indivldttele !bt I~ew Yot~ 9tatp tit~mbih'Cy bopsflttl l1N6~YISA. Ia addittm. the btasi~oea as owned by oat iadlvleluaI tx is a p~erahfp aeries the !eves of New Yaic Sott• sari >a not a eatpastioa; er ii a aa-s or.cwo.pe~ owned oo<POtallou. vrT~ those ladtvtduals owtsjpg aI! of the steak and 6oldin8 ail es~e•a of the cospnratioo. • ' 6. ?ltas iF eiiCUGlitaoees cbaa~s so friar s+btkwa' ~ASadai latut:nca •adJoc distabdiq- beott~ oevetage 7a reeluire4, rash as the 6f~ing of easplnyeea, tl~e abaveronme~d bnultaa~ WIIl immadiatsllr aA4a®apptoiptlats Nev '1Cotk State spr~fio Nocl~ga' aoa'~pa~eaotioa laktMOa attd/er d~9Aiiilify bns•Aet aavtn'gSa and sAlsa ~Rm~ataly fntnal- pcoe! o! tits! esovera~ 40 feittta eppro'vsd by the Ghaitt of llld Woeloeas' eyn Board to abs govels~ent ®tity listed !n ttfm 3 oa the fi'o~ot of this lien. • 7~~1t bated oa Ebe ors pmeeeoeed, I ceat~r dt4t the obovo•t~amed bu~esa dots sot ~caaime (eNeek box ?A. indlRr 7bat 7a.) waodorts' eam[~peat~oq inseaaac~ (apPMau-t mast ham dtaeloed O1VE of ti+t hoses feom 4a. tlsovgit eh.) '7b.) disabil3ey iwt~ itepte. (aPP~t ttal9t have cheekb 4N$ of tb• bows fiwas SR 5i:) a. ~y sib my name below, I lus'•6y':atGsm that t~ta atatemra6r male bsea~a ass tpo., that ~ 4an:o~•t modes say m4ttaiaUP !'ilea amteau~ls sod I teaks 8da a~aviE ozelar tLs yamttlttep a[ pa~~: • I $sdtC a$ttst that I n ~ !a ae~ap ~ rite rapa'r•6•atuion or eowctaht-attt wt~l c1~1 Weelrees' Oosu~ettaatioa IavV end elf ohs New Y lsivs. ~,/ 1 , / • _ , Sweet, efrice tae triis /~ ~ ~ ~ ~ '~1,. Asst' ZOQ~ Albany, AlY Noraty Pttb!!e: SEC Y 2 2003 ' JANET McHUQii . - NaOtrv t'ubRo, ale gd Wow Yark Mo. 01MC6do. ^_a9 ' QuaCrffaO In 1%Utotle~a ~`,t+ _+' ~ , , 0R Canntlolon Ehipttlef t]~sxr:Y'k 9, 8;r2S ~ . Be~spthiu is a uwom afe~svlt, etaplo'yeas of the Wotkui' tornpa~edod Snmd eata~otmdxt a~pga~t to e~xmg gavadaps sheet dNs thecae ;::,,•. . . , WC1~B.l,od (12JQ3) .tR C-~~05:2i corm ~ ~'~ 1~ r ~ • ~ ~~ ' ,~Fnva~~~~~~y. ~ ~' ~. : ' • / ~ ~..,. •.1 .5 ' r . ~ , NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8~8-997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ALLIED SAFETY MANAGEMENT INC 390 NORTH BROADWAY JERICHO NY 11753 ::;:;::1?~€i1QE3:: EC31l~t~~b:: $Y:`• TWIS:: ~f=€€~1'I~:~GAT~::::::::: `::::::::: :~::::::~2%:Q1:1:>g95::: TO:~:~'2f{I~:~~2~04~:~:::~:~:~:~:~:~:~:~: POLICYHOLDER PRK DRILLING & BLASTING INC PO BOX 190 CAMBRIDGE NY 12816 POLICY NUMBER G 1114 999-4 DATE 9/29/2003 CERTIFICATE NUMBER 869-220 CERTIFICATE HOLDER TOWN OF WAPPINGER, DUTCHESS CO 20 MIDDLEBUSH ROAD P.O. BOX 324 WAPPINGER FALLS i~TY125900324 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1114 999-4 UNTIL 12/01/2004 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 12/01/2004 IN SUCH MANNER AS TO AFFECT THIS C::RTIFICATE, 5 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO TH}!: 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. RECEIVED ~;~3 ~ ~ 2003 TOWN CLERK U-26.3 THE STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING 2073 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 ALLIED SAFETY MANAGEMENT INC 390 NORTH BROADWAY JERICHO NY 11753 POLICY NUMBER G 1165 772-3 DATE 9/29/2003 CERTIFICATE NUMBER 351-633 :~:~`RC~tiQF3:~6C31t~I~~C3'8~l:~tWi~:~E~E3:TIK:~CAT~~<:,":~`:~`: :~:::~:~:~2~:a1 ~1~20>~~!~:PTO:::~'2/{I~:~~2fl04~:~:~:~:~:~:~:~:~:~:~:: POLICYHOLDER SCHIPP CONSTRUCTION CO INC PO BOX 624 ROUTE 6 MAHOPAC NY 10541 CERTIFICATE HOLDER TOWN OF WAPPINGERS 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. 1165 772-3 UNTIL 12/01/2004 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 12/01/2004 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 WIT~~ 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. ~~~~~~ E° Gov `~ ~ ~~~~ YCWN CL~~~. U-26.3 THE STATE INSURANCE FUND .r~~~, ~~~~:~~ DIRECTOR, INSURANCE FUND UNDERWRITING 2403 CERT02-2!2001 STATE OF NEW YORK WORKERS' COMPENSATION BOARD ~~ CERTIFICATE OF PARTICIPATION IN WORKERS' COMPENSATION EIVED GROUP SELF INSURANCE AUG 2 7 2003 1a. Legal Name and Address of Business Participating in Group Self- I 1d. Business Telephone Number of B ~ R nsurance (Use Street Address Only) Heartland Auto Group, Inc. dba Heart Kia 1715 Route 9 Wappingers, Falls, NY 12590 845-296-1152 1e. NYS Unemployment Insurance Employer Registration Number of Business referenced in box "1a" lb. Effective Date of Membership in the Group valid until 1/1/2003 to 1/1/2004 49-71918-7 1c. The Proprietor, Partners or executive Officers are 1f. Federal Employer Identification Number of Business referenced in Box .~. Included in the coverage provided by this group setF insurance. Excluded. Forrn G105.51 must be filled with the Self Insurance Office. 14-1795172 2. Name and Address of the Entity Requesting Proof of Coverage (Entity 2. Name and Address of Group Self- Insurer Being Listed as Certificate Holder) Automobile Dealers WCSelf-Insurance Trust Town of Wappinger C/0 Consolidated Risk Service, Inc. 20 Middlebush Road 985 Old Eagle School Road Wappingers Falls, NY 12590 Suite #504 ~, Wayne, PA 19087 This certifies that the business referenced above in box "1a" is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law as a participating member of the Group Self- Insurer listed above in box "3" and participation in such group self-insurance is still in force. The Group Self- Insurer's Administrators will send this Certificate of Participation to the entity listed above as the certificate holder in box "2". The Group Self-Insurer's Administrator will notify the above certificate holder within 10 days IF the membership of the participant listed in box "1a" is terminated. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for a maximum of one year from the date certified by the group self-insurer. If this certificate is no longer valid according to the above guidelines and the business referenced in box "la" continues to be named on a permit, license or contract issued by the certil=rcate holder, the business must provide the certificate holder either with a new certificate or other authorized proof 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 of the Group Self-Insurer referenced above and that the business referenced in box "1a" has the coverage as depicted on this form. Certified by: Certified by: Title: Administrator Telephone: (610) 687-3869 ~~~~~~' ~us~~ ~~~l~~~s ~~~ ~~®~~®~~~s Town of Wappinger 22 Middlebush Road Wappingers Falls, NY 12590 ~~~ ~~~ ~~ ~~ti .5 ~~ .Go~`a RE: WORKERS' COMPENSATION CERTIFICATE Dear Sir: August 8, 2003 Enclosed please fmd our Certificate of Workers' Compensation Insurance. Please keep this copy on file. Respectfully, VB/ss Enclosure ~L1JtiC~iiv~ J 55 Vincent Bettina RECE~~E~ auG ~ ~ 2003 TOWN CLt~F~K PO BOX 435 •1035 MAIN STREET • FISHKILL, NY 12524 ~\~ ~ ~• e~ss~.o°cu°noH ® TEL (845) 897-8600 • FAX (845) 897-8668 "`~°" EON1L N0451Np a MIBF~IV)IIB~' OPPONTUNITV ~~i~r~ f;'~am~res~r~`c ~ ~3isak~ ,~~s,~r~Pr`x~.~r 1~'I~l 15 COMPUTER DRIVE W EST ALBANY, NEW YORK 12205-1690 Phone: (518) 437-8979 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~~~~~ ESTATE BUILDERS INC PO BOX 435 FISHKILL NY 12524 POLICYHOLDER ESTATE BUILDERS INC PO BOX 435 FISHKILL NY 12524 CERTIFICATE HOLDER TOWN OF WAPPINGER 22 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE A 1303 145-5 298952 08/13/2002 TO 08/13/2004 7/18/2003 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1303 145-5 UNTIL 08/13/2004, 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 08/13/2004 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. NEW YORK STATE INSURANCE FUND U-26.3 ~~ r~d~ DIRECTOR, INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp VALIDATION NUMBER: 1257822 i~ JEFFREY R SWEET ACTING CHAIRMAN STATE OF NEW YORK WORKERS' COMPENSATION BOARD 20 PARK STREET ALBANY, NY 12207 November 3, 2003 Dear Government Official: THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABII.ITIES WITHOUT DISCRD~IINATION. ~~~~! V G~ NOV 2 12003 SllPERVlSOR'S OFFICE TOWN OF WAPPlNGER Sections 57 and 220 Subd. 8 of the Workers' Compensation Law (WCL) require the heads of all municipal and State entities to ensure that businesses applying for permits, licenses or contracts have appropriate workers' compensation and disability benefits insurance coverage. This requirement applies to both original issuances and renewals, and also applies whether the governmental agency is having the work done or is simply issuing the permit, license or contract. It is interesting to note that these Sections ofthe Law are not new. In fact, Section 57 was originally enacted by the Legislature and signed by the Governor in 1922! I am pleased to inform you that the Workers' Compensation Board is working to make it as easy as possible for businesses, their insurance carriers, municipalities and State agencies to comply with the Law. Enclosed is documentation that will further clarify requirements under Sections 57 and 220 Subd. 8 of the WCL, including the revised forms that should be used immediately to carry out the Law. Please note that ACORD forms are NOT acceptable proof ojNew York State workers' compensation or disability benefits insurance coverage! Ensuring that businesses, receiving permits, licenses or contracts from municipal and State agencies, comply with the Workers' Compensation Law protects both injured workers and employers. In addition, such oversight helps to level the playing field, by strictly enforcing the requirement that all businesses maintain mandatory insurance coverages. Municipal and State agency cooperation in enforcing Sections 57 and 220 Subd. 8 of the Workers' Compensation Law is a critical component of encouraging business compliance. Aso enclosed is a copy of the new Section 125 General Municipal Law that requires all applicants to provide proof of workers' compensation compliance when applying for a building permit. Please note that the existing C-105.21 form will become obsolete as of December 1, 2003. This package contains extra copies ofthe new WC/DB-100 and the WC/DB-101 forms, which together replace the C-105.21 form. Form WC/DB-100 and Form WC/DB-101 are affidavits and will be used starting December 1, 2003. To be valid, the WGDB-100 and Form WC/DB-101 must be notarized and also stamped as received by the NYS Workers' Compensation Board. An extra copy ofthe BP-1 form is also included. Form WC/DB-100, Form WC/DB-101 and Form BP-1 are the only three forms that Municipal and State agencies may reproduce themselves and distribute as part of this process. You may make as many additional copies of these forms as you require. The enclosed instruction packet will identify where applicants may obtain the other forms used to enforce these sections of the Workers' Compensation Law. (An overview of all approved forms is included on the back of this letter.) Revised Form C-105.2 (12-03) is effective December 1, 2003. Earlier-dated versions ofthe form are obsolete and should no longer be issued by insurers or accepted by governmental agencies after that date. I would appreciate your notifying the permit-issuing, license-issuing and contract-making agencies or departments . within your jurisdiction of these requirements so that they may comply with the Law.. If you have any questions or require additional information, please feel free to call Steve Carbone of the NYS Workers' Compensation Board, Bureau of Compliance at (518) 486-6307. Thank you for your help in enforcing these Sections ofthe Workers' Compensation Law. Sincerely, NYS WCB NYS WCB WC/OB1l1fV101 NYS WCB wGD81ol'N1o1 NYS WCB waoetodtot WCA)B700/101 107 NYS WCB NYS WCB NYS WCB NYS WCB wcmB~oatot 100 Broadway State Office 111 Livingston Delaware WCID810N101 220 Rabro NYS WCB wGDBl0atol WpD8100V101 215 W 125th WCJD810N10t 168.46 91st NYS WCB 41 N rth Menands ALBANY Building 44 Hawley Street St. Ave. 22nd Floor BUFFALO Drive S it 100 175 Fulton A . St. o Ave. wa0at0onol Division St. 3rd Floor 130 Main St. NYS WCB wCIDBtoo/tot 12241 BINGHAMTON BROOKLYN 14202 u e HAUPPAUGE ve. HEMPSTEAD 3rd Floor NEW YORK PEEKSKILL QUEENS ROCHESTER 935 James St. (886)750- 13901 11201 (866)211• 11788 11550 10027 10566 11432 14814 (886)746- (800)877- (866)211- SYRACUSE 13203 5157 FaxA' (518) (866) 802-3604 Faxk (607) (800) 877-1373 0645 Faxk (718) Fex# (716) (866) 681-5354 FaxM (631) (866) 805-3630 Faxlt (516) (800) 877.1373 Faxi (212 0552 1373 0644 ' (886) 802.3730 473-9166 721.8324 802-6842 842.2132 952-7966 560.7807 ) 316.9183 FaxAY (914) FaxN (718) Faxli (585) 788-5793 291 7248 FaxN (315) 423• Aff idavit For N ew York Entities A nd An O ut Of State Entitle - 238-8351 W'th N E 2938 y s I o mployees, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required (Incomplete forms will be returned -Please contact an attorney if you have any questions regarding this form.) **This form cannot be used to waive the workers' compensation rights or obligations of any party including a subcontractor** The applicant may use this Affidavit ONLY to show a government entity that New York State specific workers compensation and/or disability benefits insurance is not required.. The applicant may NOT use this form to show either other businesses or those business' insurance carriers that such insurance is not required. Applicant must either fax or mail this completed form to the closest New York State Workers' Compensation Board office at th1 fax number or address listed on the top of this form. Incomplete forms will be returned Please note: Phis statement must be notarized and also have been stamped by the New York State Workers' Compensation Board. This affidavi will not be accepted by government officials one year from the date received by the Workers' Compensation Board. Upon receipt of a fully completed WC/DB 100 form, the Workers' Compensation Board will stamp this form as received and return it to you by either mail or fax. Please provide a copy (or the original, if required by the government entity) of this stamped form to the government entity from which yot are requesting a permit, license or contract. In the Application of (Business Name and Address) for a permit/license/contract State of ) ss.: County of ) (applicant's name) being duly sworn, deposes and says: 1. I am the (position) with (business or trade (type of business). The telephone number of the business is (_) Employer Identification Number of the business (or the Social Security Number of the business owner) is The New York State Unemployment Insurance Employer Registration Number (if any) of the business is that due to my position with the above-named business I have the knowledge, information and authority to make this affidavit. 2. My personal address is and my home telephone ( ) I affirn number is 3. That the above named business is applytng fora (type of permit/ license%ontracf applying for) from (governmental entity issuing the permit/ license%ontract). 3a) jOptional Location of where work will be performed in New York State -- from to (dates necessar} to complete work associated with permit/license%ontracf). The estimated dollar amount of project is . J 4. That the above named business is certifying that it is exempt from obtaining New York State specific workers' compensation insurance coverage for the following reason (to be eligible for exemption, applicant must be able to truthfully check ONE of the boxes from 4a. through 4h.): ^ 4a.) the business is owned by one individual and is not a corporation. Other than the owner, there are no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). ^ 4b.) the business is a partnership under the laws of New York State and is not a corporation. Other than the paztners, there are no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). (Must attach separate sheet with a list of all the partners names and also with the signatures of all the partners.) ^ 4c.) the business is a one person owned corporation, with that individual owning all of the stock and holding all offices of the corporation Other than the corporate owner, there aze no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). name), The Federa] WC/DB 100 (12/03) {Replaces C-105.21 Form } (Over) NYS WCB ' NYS WCB NYS WCB rvra wt,B wcro9foatot wcmBfoatof 100 Broadway wcm9toatof State Office wc~oBttlafot 11 107 NYS WCB W~efofvlof NYS WCB NYS WCB NYS WCB NYS WCB wcmBfoatot Menands Building 1 Livingston St Delaware 220 Rabro Waoefoalot wcmettftvfol 215 W 125th wGOBloo~fof 168-46 91st NYS WCB ALBANY 12241 44 Hawley Street 22nd Floor Ave. BUFFALO Drive Suite 100 775 Fulton . y^t, 41 North Division St. Ave. 3rd Floor wGDBton'foi 1 NYS WCB (866)750- BINGHAMTON 13901 BROOKLYN 11201 14202 HAUPPAUGE AVe HEMPSTEAD 3rd Floor NEW YORK PEEKSKILL OUEENS 30 Main St. ROCHESTER wcm9fon~fof 935 James St 5157 Faxa (518) (866) 802-3604 Fafcll (607) (800) 877.1373 F (866)211- 0845 11788 (~ a 8 4 11550 (86 05- ~ 10027 ( 10566 (868) 746- 11432 (800) 877- 14614 (886) 211- . SYRACUSE 132 473-9166 721.8324 axk (718) 802-8642 Fafdf (716) 842-2132 F ft5 (831~ 952 6 8 ~~ 212)73 0552 Fafdi (914) 1373 Faxk 71 0644 03 (886)802-3730 -7986 560-7807 316.9183 788.5793 291-7248) 238.8351) F~2938 423- Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Compensation And/Or Disability Benefits Insurance Coverage Is Not Required (Incomplete forms will be returned -Please contact an attorney if you have any questions regarding this form.) **This form cannot be used to waive the workers' compensation rights or obligations of any party including a subcontractor** The applicant may use this Affidavit ONLY to show a government entity that New York State specific workers compensation and/or disability benefits insurance is not required. The applicant may NOT use this form to show either other businesses or those business' insurance carriers that such insurance is not required. Applicant must either fax or mail this completed form to the closest New York State Workers' Compensation Board office at th1 fax number or address listed on the top of this form. Incomplete forms will be returned Please. note: This statement must be not 'red and also have been stamped by the New York State Workers' Compensation Board. This aff~davi will not be accepted by government officials one year from the date received by the Workers' Compensation Board. Upon receipt of a fully completed WC/DB l00 form, the Workers' Compensation Board will stamp this form as received and return it to you by eithe mail or fax. Please provide a copy (or the original, if required by the government entity) of this stamped form to the government entity from which yot are requesting a permit, license or contract. In the Application of (Business Name and Address) for a State of County of pernuUlicense/contract ss.: (applicant's name) being duly sworn, deposes and says: 1. I am the (position) with (business or trade (type of business). The telephone number of the business is ( ) Employer Identification Number of the business (or the Social Security Number of the business owner) is The New York State Unemployment Insurance Employer Registration Number (if any) of the business is that due to my position with the above-named business I have the knowledge, information and authority to make this affidavit. 2. My personal address is and my home telephone r ~ number is 3. That the above named business is applying fora (type of permit/ license%ontrac~ applying for) from (governmental entity issuing the permit license%ontract). 3a) (Optional -- Location of where work will be performed in New York State from to (dates necessary to complete work associated with permit/license%ontract). The estimated dollar amount of project is f 4. That the above named business is certifying that it is exempt from obtaining New York State specific workers' compensation insurance coverage for the following reason (to be eligible for exemption, applicant must be able to truthfully check ONE of the boxes from 4a. through 4h.): ^ 4a.) the business is owned by one individual and is not a corporation. Other than the owner, there are no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). ^ 4b.) the business is a partnership under the laws of New York State and is not a corporation. Other than the partners, there are no employees, leased employees, borrowed employees, part-time employees, subcontractors or unpaid volunteers (including family members). (Must attach separate sheet with a list of all the partners names and also with the signatures of all the partners.) ^ 4c.) the business is a one person owned corporation, with that individual owning all of the stock and holding all offices of the corporation Other than the corporate owner, there are no employees, leased employees, borrowed employees, part-time employees, . subcontractors or unpaid volunteers (including family members). name), The Federal I affirm WC/DB 100 (12/03) {Replaces C-105.21 Form } (Over) NYS WCB WGDB10t)/101 NYS WCB WGDB700/101 ~ NYS WCB wGDe NYS WCB WGDB700/101 NYS WCB NYS WCB NYS WCB 100 Broadway State Office loalol 111 Livingston 107 Delaware wGDBloaiol 220Rab C 5D ~~ NYS WCB w o1 wGDBloalol 168-4691st Menands Building St. Ave. ro D i WGDB700/ o1 21 W Sth q~N~n Ave NYS WCB WGD ALBANY 12 44 Hawley Street 22nd Floor BUFFALO r ve Suite 100 175 Fulton St. Division St. ' 3rd Floor Bloonol 130 Main St NYS WCB wG 241 (866)750- BINGHAMTON 13901 BROOKLYN 14202 HAUPPAUGE HEMPSTEAD NEW YORK PEE 1LL QUE~2S . ROCHESTER OBloa~ol 935 James St. 5157 (866)802-3604 17201 (800)877.1373 (866)211- 0645 11788 (866) 681.5354 11550 10027 0566 (866)746- (800)877- 14614 (866)211- SYRACUSE Fax# (518) 473-9166 FaxN (607) 721 8324 Fax# (718) Fax# (716) . Fax1i (631) (866)805-3630 Faxti (516) (BFax# 212)73 13203 (866)802.3730 - 802-6642 842-2132 .952.7966 560.7807 31f Q1az Fax# (914) ~„ ~~,,,, Fax# (718) Faxi (585) Fax# (315) 423- . •_ __-__.~_. ~..._v_ . ~.,..~.,.,.~~ ,,,~, ~~1,x~st~.~~ucairce::~overa (Incomplete forms will be returned -Please contact an attorney ifyou have any questions regarding this jorm.) "XThis form cannot be used to waive the workers' compensation rights or obligations of any party including a subcontractor'~X The applicant may use this Affidavit ONLY to show a government entity that New York State specific workers' compensation and/or disability benefits insurance is not required. The applicant may NOT use this form to show either other businesses or those business' insurance carriers that such insurance is not required. Applicant must either fax or mail this completed form to the closest New York State Workers' Compensation Board office at the fax number or address listed on the top of this form. Incomalete forms will be returned Please note: This statement must be notarized and also have been sta. tuned by the New York State Workers' Compensation Board. This affidavit will not be accepted by government officials one year from the date received by the Workers' Compensation Board. Upon receipt of a fully completed WC/DB-101 form, the Workers' Compensation Board will stamp this form as received and return it to you by either mail or fax. Please provide a copy (or the original, if required by the government entity) of this stamped form to the government entity from which you are requesting a permit, license or contract. In the Application of (Business Name and Address) fora permidlicense%ontract State of ) ss.: County of ) (applicant's name) being duly sworn, deposes and says: 1. i am the (position) with (business or trade name), a (type of business). The telephone number of the business is ( ) The Federal Employer Identification Number of the business (or the Social Security Number of the business owner) is The New York State Unemployment Insurance Employer Registration Number (if any) of the business is I affirm that due to my position with the above-named business I have the knowledge, information and authority to make this affidavit. 2. My personal address is number is ( ) 3. That the above named business is applying for a applying for) from 3a) (Optional -- Location of where work and my home telephone (type of permit/ license%ontract _ (governmental entity issuing the permit/license%ontract). will be performed in New York State from to (dates necessary to complete work associated with permit/license%ontract). The estimated dollar amount of project is 4. That the above named business is certifying that it is exempt from obtaining New York State specific workers' compensation insurance coverage for the following reason (to be eligible for exemption, applicant must be able to truthfully check either box 4a or 4b): WC/DB-101 (12/03) {Replaces C-105.21 Form} (Over) NYS WCB WGD81txY101 NYS WCB WGD6100/101 NYS WCB NYS WCB WGD8100/101 NYS WCB )0 Broadway State Office WGDB100/101 111 Livingston 107 Delaware WGD61oa1o1 Menands Building St 220 Rabro ALBANY 12241 44 Hawley Street BINGHAMTON 22nd Floor BUFFALO Drive (866) 750- 13901 BROOKLYN 11201 14202 HAUPPAUGE 5157 Fax# (518) (866)802-3604 F # (800)877-1373 (866) 211- 0645 11788 (866)681-5354 473 9166 ax (607) 721 832 Fax# (718) Fax# (716) Fax# (631) . -,_. . 4 ._. Y 802-6642 842-2132 cFOnora NYS WCB NYS WCB wGDBloalol wGD61oa1o1 215 W. 125th 175 Fulton St. Ave. 3rd Floor HEMPSTEAD NEW YORK 11550 10027 (866)805-3630 (800)877.1373 Fax# (516) Fax# (212) NYS WCB NYS WCB WGD8100/101 WGDB100/101 168-46 91st 41 North Ave. Division St. 3rd Floor PEEKSKILL QUEENS 10566 11432 (666)746- (800)877- 0552 1373 Fax# (914) Fax# (718) NYS WCB WGD8100/101 NYS WCB 130 Main St. wGD6100/io1 ROCHESTER 935 James St. 14614 SYRACUSE (866)211- 13203 0644 (866)802.3730 Fax# (585) Fax# (315) 423- ~~-~~r~a~+tr~~ti!ter~E~-,~sr~r nce~ove:~age (Incomplete forms will be returned -Please contact an attorney if you have any queshons regarding this form.) '~'•`This form cannot be used to waive the workers' compensation rights or obli ations o an ,~~ g f y party including a subcontractor The applicant may use this Affidavit ONLY to show a government entity that New York State specific workers' compensation and/or disability benefits insurance is not required. The applicant may NOT use this form to show either other businesses or those business' insurance carriers that such insurance is not required. Applicant must either fax or mail this completed form to the closest New York State Workers' Compensation Board office at the fax number or address listed on the top of this form. Incomplete forms will be returned Please note: This statement must be notarized and also have been stamped by the New York State Workers' Compensation Board. This affidavit will. not be accepted by government officials one year from the date received by the Workers' Compensation Board. Upon receipt of a fully completed WC/DB-101 form, the Workers' Compensation Board will stamp this form as received and return it to you by either mail or fax. Please provide a copy (or the original, if required by the government entity) of this stamped form to the government entity from which you are requesting a permit, license or contract. In the Application of (Business Name and Address) for a State of County of ss.. permiblicense/contract (applicant's name) being duly sworn, deposes and says: 1. I am the (position) with (business or trade name), a (type of business). The telephone number of the business is (-) The Federal Employer Identification Number of the business (or the Social Security Number of the business owner) is The New York State Unemployment Insurance Employer Registration Number (if any) of the business is I affirm that due to my position with the above-named business I have the knowledge, information and authority to make this affidavit. 2. My personal address is number is ( ) 3. That the above named business is applying for a applying for) from 3a) (Optional -- Location of where work and my home telephone (type of permit/ license%ontract _ (governmental entity issuing the permit/license%ontract). will be performed in New York State from to (dates necessary to complete work associated with permit/license%ontract). The estimated dollar amount of project is .) 4. That the above named business is certifying that it is exempt from obtaining New York State specific workers' compensation insurance coverage for the following reason (to be eligible for exemption, applicant must be able to truthfully check either box 4a or 4b): WC/DB-101 (12/03) {Replaces C-105.21 Form} (Over) affidavit of Exemption to Show Specific Proof of Workers' Com pensation I Coverage fora 1, 2, 3 or 4 Farruly, Owner-occupied Residence nsurance Under penalty of perjury, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, and I am not required to show specific proof of workers' compensation insurance coverage for such residence because (please check the appropriate box): ^ I am performing all the work for which the building permit was issued ^ I am not hiring, paying or compensating in any way, the individual(s) that is(are) performing all the work for which the building permit was issued or helping me perform such work. ^ I have a homeowners insurance policy that is currently in effect and covers the property listed.on the attached building permit AND am hinng or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for which the building permit was issued. I also agree to either: • acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if I need to hire or pay individuals a total of 40 hours or more per week (aggregate hours for all paid individuals on the jobsite) for work indicated on the building permit; OR • have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, provide appropriate proof of workers' compensation coverage or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if the project takes a total of 40 hours or more per week (aggregate hours for all paid individuals on the jobsite) for work indicated on the building permit. (Signature of Homeowner) (Date Signed) Home Telephone Number (Homeowner's Name Printed) Property Address that requires the building permit: BP-1 (3/99) STATE & MUNICIPAL AGENCY REQUIREMENTS UNDER GENERAL MUNICIPAL LAW §125 & wcL §s~ & §zzo FOR WORKERS' COMPENSATION AND DISABILITY BENEFITS Please call Steve Carbone at (518) 486-6307 if you have any questions. November 3, 2003 JEFFREY R SWEET ACTQJG CHAIRMAN STATE OF NEW YORK WORKERS' COMPENSATION BOARD 20 PARK STREET ALBANY, NY 12207 November 3, 2003 Deaz Government Off cial: THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABII.TTIES WITHOUT DISCRA~@iATION. Sections 57 and 220 Subd. 8 of the Workers' Compensation Law (WCL) require the heads of all municipal and State entities to ensure that businesses applying for permits, licenses or contracts have appropriate workers' compensation and disability benefits insurance coverage. This requirement applies to both original issuances and renewals, and also applies whether the governmental agency is having the work done or is simply issuing the penmit, license or contract. It is interesting to note that these Sections of the Law are not new. In fact, Section 57 was originally enacted by the Legislature and signed by the Governor in-1922! I am pleased to inform you that the Workers' Compensation Board is working to make it as easy as possible for businesses, their insurance carriers, municipalities and State agencies to comply with the Law. Enclosed is documentation that will further clarify requirements under Sections 57 and 220 Subd. 8 of the WCL, including the revised forms that should be used immediately to carry out the Law. Please note that ACORD forms are NOT acceptable proof of New York State workers' compensation or disability benefits insurance coveragel Ensuring that businesses, receiving permits, licenses or contracts from municipal and State agencies, comply with the Workers' Compensation Law protects both injured workers and employers. In addition, such oversight helps to level the playing field, by strictly enforcing the requirement that all businesses maintain mandatory insurance coverages. Municipal and State agency cooperation in enforcing Sections 57 and 220 Subd. 8 ofthe Workers' Compensation Law is a critical component of encouraging business compliance. Also enclosed is a copy of the new Section 125 General Municipal Law that requires all applicants to provide proof of workers' compensation compliance when applying for a building permit. Please note that the existing C-105.21 form will become obsolete as of December 1, 2003. This package contains extra. copies ofthe new WC/DB-100 and the WC/DB-101 forms, which together replace the C-105.21 form. Form WC/DB-100 and Form WC/DB-101 are affidavits and will be used starting December 1, 2003. To be valid, the WC/DB-100 and Form WC/DB-101 must be notarized and also stamped as received by the NYS Workers' Compensation Board. An extra copy ofthe BP-1 form is also included. Form WC/DB-100, Form WC/DB-101 and Form BP-1 are the only three forms that Municipal and State agencies may reproduce themselves and distribute as part of this process. You may make as many additional copies of these fonms as you require. The enclosed instruction packet will identify where applicants may obtain the other forms used to enforce these sections of the Workers' Compensation Law. (An overview of all approved forms is included on the back of this letter.) Revised Form C-105.2 (12-03) is effective December 1, 2003. Earlier-dated versions of the form are obsolete and should no longer be issued by insurers or accepted by governmental agencies after that date. I would appreciate your notifying the permit-issuing, license-issuing and contract-making agencies or departments within your jurisdiction of these requirements so that they may comply with the Law. If you have any questions or require additional information, please feel free to call Steve Cazbone of the NYS Workers' Compensation Board, Bureau of Compliance at (518) 486-6307. Thank you far your help in enforcing these Sections ofthe Workers' Compensation Law: Sincerely, WORKERS' COMPENSATION LAW §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 tc 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, boazd, 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. DISABILITY BENEFITS LAW §220. Subc~. S (a) The head of a state or municipal department, boazd, 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, boazd, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, boazd, 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. STATE & MUNICIPAL AGENCY COMPLIANCE WITH §57 WCL November 3, 2003 Section 57 -- Restriction on Issue of Permits and the Entering of Contracts Unless Compensation Is Secured Section 57 of the Workers' Compensation Law (WCL) requires the heads of all State and municipal entities, prior to issuing any permits, licenses or entering into contracts, to ensure that businesses applying for those permits, licenses or entering into contracts have appropriate workers' compensation insurance coverage. To comply with coverage provisions of the Workers' Compensation Law, businesses must: A) be legally exempt from obtaining workers' compensation insurance coverage. B) obtain such coverage from insurance carriers; or C) be self-insured. To .assist State and municipal entities in enforcing Section 57 of the Workers' Compensation Law, businesses requesting permits, licenses or seeking to enter into contracts must provide ONE of the following forms to the entity issuing the permit, license or entering into a contract: A) WC/DB-100, Affidavit For New York Entities And Any Out Of State Entities With No Employees, That New York State Workers' Compensation Arid/nr n;cah;hty Ranpfi+~ r„~,,,..,«„e ~,._...-...__ T_ 1L~,1 B) C-105.2 -- Certificate of Workers' Compensation Insurance (the business' insurance carrier will send this form to the government entity upon the business' request) PLEASE NOTE: The State Insurance Fund provides its own version of this form, the U-26.3; OR C) SI-12 -- Certificate of Workers' Compensation Self-Insurance or GSI-105.2 -- Certificate of Group Workers' Compensation Self-Insurance (Please note: ACORD forms are NOT acceptable proof of workers' compensation coverage!) Government Officials Local Contacts with the NYS Workers' Compensation Board Government Officials should call the Workers' Compensation Boazd's Enforcement Unit in the neazest district office to notify them of a business in noncompliance: Albany (518) 486-3349 Manhattan (212) 932-7576 Binghamton (607) 721-8334 Peekskill (914) 788-5804 Brooklyn (718) 802-6870 Queens (718) 523-8409 Buffalo (716) 842-2057 Rochester (585) 238-8335 Hauppauge (631) 952-6698 Syracuse (315) 423-1141 Hempstead (516) 560-7742 How a Business Requests a SI-12 Form or a GSI-105.2 Form Businesses should call the Workers' Compensation Boazd's Self-Insurance Office to obtain a SI-12 -- Certificate of Workers' Compensation Self-Insurance at (518) 402-0247 or contact their Group Self-Insurance Administrator for a copy of the GSI-105.2 -- Certificate of Group Workers' Compensation Self-Insurance. Please call the Bureau of Compliance at (518) 486-6307 with any general questions regarding Section 57 of the Workers' Compensation Law. -1- , ~~._......_~~ ~u~~ u~ s~ampeu as recetvea by the NYS Workers' Compensation Board); OR