1987/2007 (21)Section 57 Restriction on issue of permits and the entering into eontra~ts 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 ti~is 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 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
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CERTIFICATE OF PARTICIPATION IN WORKERS' COMPENSATION
GROUP SELF-INSURANCE
la. Legal Name and Address of Business Participating in Group ld. Business Telephone Number of Business Referenced in box "la"
Self-Insurance (Use Street Address Only)
Greystone Programs, Inc. 845-297-8800
24 DeLavergne Street
Wappingers Falls, NY 12590
le. NYS Unemployment Insurance Employer Registration Number of
Business referenced in box "la"
1 b. Effective Date of Membership in the Group 04-57539 2
04/06/04
lc. The Proprietor, Partners or Executive Officers are lf. Federal Employer Identification Number of Business referenced in
X included in the coverage provided by this group self-insurance. Box "la"
^ excluded. Form C-105.51 must be filed with the Self-Insurance
Office. 14-1608318
2. Name and Address of the Entity Requesting Proof of Coverage 2, Name and Address of Group Self-Insurer
(Entity Being Listed as Certificate Holder)
Town of Wappinger Health Care Providers Self-Insurance Trust
20 Middlebush Road 99 Troy Road, Suite 200
Wappingers Falls, NY 12590 East Greenbush, NY 12061
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 "1 a" 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 "1 a "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 representation of the Group Self-Insurer
referenced above and that the business referenced in box "la" has the coverage as depicted on this form.
Certified by:
Certified by:
Title:
Tnhn lUT (`nnrnv
Telephone Number: (518) 456-5557
GSI-105.2 12-00
~~ ~
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CERTIFICATE OF PARTICIPATION IN WORKERS' COMPENSATION
-- --~ GROUP SELF-INSURANCE
ia. Legal Name and Address of Business Participating in Group
Self- Insurance (Use Street Address Only)
1d. Business Telephone Number of Business referenced in box "1 a"
845-462-1800
Sun Up Enterprises Inc
1607 Rt 376
Wappingers Falls, NY 12590
04/01 /05 -
1b. Effective Date of Membership in the Group 04/01/06
ic. The Proprietor, Partners or Executive Officers are:
included. (Only check box if all partners/officer included)
all excluded or certain partners/officers excluded
2. Name and address of the Entity Requesting Proof of
Coverage (Entity Being Listed as Certificate Holder)
Town of Wappinger
PO Box 324
Wappingers Falls, NY 12590
1e. NYS Unemployment Insurance Employer Registration Number of
Business referenced in box "1 a" ~
r
41-755135
1f. Federal Employer Identification Number of Business
referenced in Box "1 a"
141626397
and address of Group
Elite Contractors Trust of NY
112 Delafield Street
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 maybe 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'tlii.s certificate is no longer valid according to the above guidelines and the business referenced in box "la"continues to be
rtarned on a permit, license or contract issued by the certificate holder, the business must provide the certificate holder either
ti,.~ith cz new cert~cate 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 "l a" has the coverage as depicted on this form.
Certified by: John R. Peluse
(Print name of authorized representative of the Group Self-Insurer)
Certified by: ~ 3/14/2005
(Signature) (Date)
Title: A:.....,.~z.,.. Ke resentative
Telephone: 845-297-1700
GSI-105.2 (2-02)
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1 a. Legal Name and address of Insured (Use street address only) lb. Business Telephone Number of Insured
Central Hudson Gas & Electric Corporation 845-486-5774
284 South Avenue lc. NYS Unemployment Insurance Employer Registration
Poughkeepsie, NY 12601 Number of Insured
48-100046
1 d. Federal Employer Identification Number of Insured or
Social Security Number
Work Location of Insured (Only required if coverage is specifically 14-0555980
limited to certain locations in New York State, i.e. a Wrap-Up Policy)
2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier
Coverage (Entity Being Listed as the Certificate Holder)
Travelers Indemnity Company of America
Town of Wappinger 3b. Policy Number of entity listed in box "la":
20 Middlebush Road
Wappinger Falls, NY 12590 TC2HUB281D1960-05
3c. Policy effective period:
1/1/05 to 1/1/06
3d. The Proprietor, Partners or Executive Officers are:
X included. (Only check box if all partners/officers included)
^ all excluded or certain partners/officers excluded.
3e. Demolition is: (Definition of Demolition on Reverse)
X included.
^ excluded.
This certifies that the insurance carrier indicated above in box " 3" insures the business referenced above in box "la" for workers'
compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under
Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its
licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2".
The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums
or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the
coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for a maximum of
nne 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 holder, the business must provide that certificate holder with a new Certificate of Workers'
Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York
State Workers' Compensation Law.
Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced
above and that the named insured has the coverage as depicted on this form.
Approved by: y ° J~~ `+ 'y- ~a ,mss
(Print name of authorized representative or licensed agent of insurance Gamer) DEC 2 3 2004
,.--_ ~
Approved by:
~/a y
(Date)
Title: ~ ~ ~ ~ ~^~'~'' '~~17
Telephone Number of authorized representative or licensed agent of insurance carrier:
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 (12-03)
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 pemut for or in
connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding
any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by
an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this
chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board,
commission or office to pay any compensation to any such employee if so employed.
2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or
in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding
any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed
by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by
this chapter.
Definition of Demolition (Box " 3e." on the reverse side of this form)
A building wrecking or demolition is one where a building, chimney or steeple is razed, or where a floor, exterior wall or roof is removed.
If the contract involves only the removal of interior walls, partitions or the facing only of any exterior wall, it is not considered demolition.
Out-of--State Companies Working in NYS -- NYS Workers' Compensation and Disability Benefits Requirements for Permits,
Licenses or Contracts issued by NYS Government Entities
Generally, employers must have a workers' compensation policy or a combination of policies that cover each state in which they employ
permanent employees to cover on-the job accidents and disabilities. As you are probably aware, certain insurance carriers write policies
that cover multiple states. "Riders" found under sections 3A and 3C on the Information Page of the policy specify the states of coverage. In
addition, the operations covered in each state are identified in attachments to the policy.
In addition to any other state's workers' compensation coverages, an out-of--state employer needs to be specifically covered for NYS
workers' compensation insurance when there are "sufficient contacts" between that employer and the state. While there is no single
determinative factor, any of the following criteria could be the basis for fmding "sufficient contacts" requiring New York coverage:
• a physical location within New York State;
• $50,000 in payroll during a calendar year in New York State;
• one or more employees (including subcontractors) with a primary work location or hired within New York State; or
• employees (including subcontractors) working in New York State for more than 90 days during a calendar year.
If an out-of--state employer meets any of the above criteria, it is required to carry a New York State workers' compensation policy. When
New York is listed in Item 3A on the Information Page of an employer's workers' compensation insurance policy, the employer is tuiiy
covered under the NYS Workers' Compensation Law. If insured through a private insurance carrier, the out-of--state employer must file a
C-105.2 -- Certificate of Workers' Compensation Insurance (the business' insurance carrier will send this form to the government entity
upon request) PLEASE NOTE: The New York State Insurance Fund provides its own version of this form, the U-26.3. If the out-of--state
employer is legally, fully self-insured in New York State, the out-of-state employer must file a SI-12 -- Certificate of Workers'
Compensation Self-Insurance (the business calls the Board's Self-Insurance Office at 518-402-0247). If the out-of-state employer is
participating in group self-insurance, the out-of-state employer must file a GSI-105.2 -- Certificate of Participation in Worker's
Compensation Group Self-Insurance (the business' Group Self-Insurance Administrator will send this form to the government entity upon
request).
If an out-of--state employer does not meet any of the above criteria and has New York (NY) listed in Item 3C on the Information Page of its
workers' compensation insurance policy (the Other States Insurance section), NYS specific coverage is not required and the employer may
be able to use its own state's workers' compensation coverage by filing a WC/DB-101. form. [The out-of--state employer's employees will be
covered under NY benefits when working in New York by having NY listed in Item 3C on the Information Page of the workers'
compensation insurance policy (the Other States Insurance section).]
C-105.2 (12-03) Reverse
- ~~ PRESENTATION O
VERVIEW ~~
WORKERS' COMPENSATION LAW -- SECTIONS 57 AND 220 SUBD. 8
1. Definition of Workers' Compensation and Disability Benefits
• WC covers job related accidents, injuries, illnesses -Benefits 2/3 average weekly wage up to $400 per week
plus all related medical expenses.
• DB covers non job related accidents, injuries, illnesses -- Benefits 1/2 average weekly wage up to $170 per
week for maximum of 26 weeks; NO medical expenses.
2. How this insurance benefits both employers and employees
• Employees -- No fault, "prompt payment" of benefits
• Employers -- Sole remedy coverage - "eliminates" lawsuits and personal liability
3 . Why municipal or State employees have to .check on this insurance coverage
• §57 & §220 WCL requirement
• Part of public protection responsibilities
4. What happens if an employer is supposed to have this coverage and doesn't
• Employer personally liable for full compensation and medical claim payments; penalties; administrative
expenses; and possible criminal charges.
• Employee initially paid by Uninsured Employer's Fund - a process that takes two to three years before
compensation or medical bills are paid.
5. How municipal or State employees check on this insurance coverage
(Please note: businesses must supply appropriate form(s) once per year)
WC & DB • WC/DB-100, 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; OR WC/DB-1D1. -
_.
(Affidavits mast be stamped as received by the
NYS Workers' Compensation Board);
WC • C-105.2 -Certificate of Worker's 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
WC • SI-12 -- Certificate of Worker's Compensation Self-Insurance, GSI-105.2 - Certificate of Participation
in Worker's Compensation Group Self-Insurance
(Please note: ACORD forms are NOT acceptable proof of workers' compensation coverage!)
DB • Either the DB-120.1 - Certificate of Disability Benefits Insurance OR the DB-820/829
Certificate/Cancellation of Insurance (the business' insurance carrier will send one of these forms to the
government entity upon request); OR
DB • DB-155 -Certificate of Disability Benefits Self-Insurance.
6. Out-of--state employers need specific NYS workers' compensation coverage
if they meet any of the following criteria:
• Permanent NYS Location
• Hire an employee (or subcontractors) in NYS
• Pay over $50,000 per year to employees while they work in NYS
• Employees (or subcontractors) assigned to work over 90 days in NYS during a calendar year.
Disability benefits coverage is required if the business employs individuals in NYS for more than 30 days in a calendar year.
7. General Contr'actors/Independent Contractors/Subcontractors
• General Contractors must get a workers' compensation insurance policy if they hire any subcontractors or
independent contractors.
r '
~o~ember 3, 2003
~~
WORKERS' COMPENSATION REQUIt~. ~~ ~TNDER WCL §57
To comply with coverage provisions of the Workers' Compensation Law, businesses must:
A) be legally exempt from obtaining workers' compensation insurance coverage; or
B) obtain such coverage from insurance carriers; or
C) be self-insured or participate in an authorized group self-insurance plan.
To assist State and municipal entities in enforcing Section 57 of the Workers' Compensation Law, businesses
requesting permits or seeking to enter into contracts MUST provide ONE of the following forms to the
government entity issuing the permit 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 And/Or Disability Benefits
Insurance Coverage Is Not Required; OR
B) C-105.2 -- Certificate of Workers' Compensation Insurance (the business' insurance carrier will
send this form to the government entity upon 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 (the business calls the Board's Self-
Insurance Office at 518-402-0247), OR GSI-105.2 -- Certificate of Participation in Worker's
Compensation Group Self-Insurance (the business' Group Self-Insurance Administrator will send
this form to the government entity upon request).
DISABILITY BENEFITS REQUIREMENTS UNDER WCL §220 SUBD 8
To comply with coverage provisions of the Disability Benefits Law, businesses may:
A) be legally exempt from obtaining disability benefits insurance coverage; or
B) obtain such coverage from insurance carriers; or
C) be self-insured.
Accordingly, to assist State and municipal entities in enforcing Section 220 Subd. 8 of the Disability Benefits
Law, businesses requesting permits or seeking to enter into contracts MUST provide ONE of the following
forms to the entity issuing the permit 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 And/Or Disability Benefits
Insurance Coverage Is Not Required; OR
B) Either the DB-120.1 -- Certificate of Disability Benefits Insurance OR the DB-820/829
Certificate/Cancellation of Insurance (the business' insurance carrier will send one of these forms to
the government entity upon request); OR
C) DB-155 -- Certificate of Disability Benefits Self-Insurance (the business calls the Board's Self-
Insurance Office at 518-402-0247).
(Affidavits must be stamped- as received by the NYS Workers' Compensation Board)
(Affidavits must be stamped as received by the NYS Workers' Compensation Board)
First Cardinal
C O R P O RAT I O N
7/14/2003
Town of Wappinger
PO Box 324
Middlebush Road
Wappingers Falls, NY 12590
RE: WORKERS' COMPENSATION CARRIER CERTIFICATE # 007000000303103
Sloper-Willen Community AmbuJ.ance Servic
To whom it may concern:
Our records reflect that you are a certificate holder on the
above captioned certificate.
Please be advised that this employer is under
cancellation notice to be effective on 8/14/2003.
Should the policy be reinstated, your office will be
notified.
If you have any questions regarding this matter, please
contact our office.
T n you,
~ ~
POLIC SERVICES DEPARTMENT
pc: File
Agent#: 1 First Cardinal Corp.
administraaors of Cardinal COMP"
:NY Oj{inr: AI RANY RU FFA LCI I.ON(; ISIAND MA~HA"f TAN
2UCHF.STF.R SYM(:UtiI~. AfA O(}r'rer.- ROSTIJN SPRIWGFI F.I.D
cE~~ ~~`.
RE
TowN G~ERK
~v` 18 2~~~
10 British American Blvd.
Latham, NY 12110
518-213-1900
866-850-COMP (2667)
Fax 518-213-1901
www.firstcardinal.com
NEW YORK STATE INSURANCE FUND
199 CHURCH STREET NEW YORK N.Y. 10007-1100
1-8~8-997-3863
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
LOVELL SAFETY MGMT CU L L C
125 MAIDEN LANE JAH 15 2003
NEW YORK NY 10038
St1PERVi~ OFFICE
TOWN OF WAPPtN(~ER
::;:::: RL~ti'QE3::E01/~RECS::BY:::T:WI~::Ir~Et7'I~:FCA7f ::::::::::::::::`•:::
:::::::::~:a~~l ra>~~~::ro::::::~~~~~:~:2004 ::::::::::::::::::::::::::
POLICYHOLDER
P J EXTERIORS INC
1589 ROUTE 376
WAPPINGERS FALLS NY 12590
POLICY NUMBER
G 1003 277-9
DATE
12/09/2002
CERTIFICATE NUMBER
447-463
CERTIFICATE HOLDER
TOWN OF WAPPINGERS
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS NY 12590
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE
INSURANCE FUND UNDER POLICY N0. 1003 277-9 UNTIL 4/01/2004 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 4/01/2004 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 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.
U-26.3
THE STATE INSURANCE FUND
,tM~~, l~ rL~:.r~~
DIRECTOR, INSURANCE FUND UNDERWRITING
a
22883 CERT02-2/2001
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
APPLICATION FOR CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
The undersigned Employer desires to obtain a Certificate of Workers' Compensation Insurance from the "'
Insurance Carrier Empire State Transportation Trust T)
as satisfactory proof required under the provisions of Section 57 of the Workers' Compensation law, to be filed with
Sloper Willen Community Ambulance
Name
(Name of Buroaq Department, Corporation, Frm w NAmtlual)
Address. P.O. Box 575, 16 Middlebush Road, Wappingers Falls, NY 12590
Locations of (operations.
Town of Wappinger
Date operations to begin: ON GOING
Telephone No. ~~~^ ~-~ ~7 3 77 ~ Signature ! ~ / ~~ie- ~/~
(Name or pbyar) (Date)
NOTE This applicatton must be sgned by the Employer If an IndNUiual, or If a I copartnerh~p by a member of the
copartnenhip, or by an officer if a corporation
This is to certify that
is insured wdh the
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
Sloper Willen Community Ambulance
Empire State Transportation Trust
under Policy No 00098726 covering the entire obligation of this employer for workers' compensation
under the New York Workers' Compesation Law with respect to the locetlons named in the foregoing application
01/01/03 01/01/04
The policy term, covers the penod from to
If said policy Is changed or canceled dunng its term. In such manner as to affect this Certficate, thirty (30) days
written notice of such change or cancellation [ten (to) days written notice in the event of cancellation for non-
payment of premium] will be gnren to
Town of Wappinger, P.O. Box 324, Middlebush Road, Wappingers Falls, NY 12590
(Name of BUleau, Department, GorporaWn, Fam or mtlmtlualJ (AOdreaE)
in accordance with whose requirements, this Certificate has been issued. Notice by registered or certified mail,
return receipt requested, so addressed shall be sufficient commpliance with this provision
Corner Empire State Transportation Trust
Telepnone No. 845-855-3300
By
(S,pnawro) a )
Title
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE Wmi DISABILITIES WITHOUT DISCRIMINATION
'JAN 2 3 2003
~VI~R'S OFFICE
OF WAPPiNGER
C-052 (~09a)
The Daniels Agency
. - : ~ ~ - ~. -r._
January 17, 2003
Louise Dalton
Sloper Willer. Community Ambulance
PO BOX 575, 1.6 Middlebush Road
Wappingers Falls, NY 12590
RE: Certificate of Insurance - Town of Wappinger
Dear Ms. Dalton:
Enclosed please find two copies of a certificate of insurance
issued to the Town of Wappinger. Please sign one and forward
directly to the Town and sign the second one and forward to the
Empire State Transportation Trust at your earliest convenience.
Should you have any questions or need anything further, please
feel free to give me a call.
Sincerely,
y
Angela Nash
Customer Service Representative
AMN~1002056 _ ._ .. ...~:_'-~~;~
527 Route 22 • Pawling, NY 12564-1200 • (845) 855-3300
FAX (845) 855-1860 • Email: daniels@danielsagency.com • www.danielsagency.com