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2008STATE OF NEW YORK WORKERS' COMPENSATION BOARD GS P4 K3 CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name and address of Insured IUse street address only) 1 b. Business Telephone Number of Insured j (845)463-0335 DAVE SOLTISH DBA SOLTISH ELECTRIC 8 SCOFIELD HTS POUGHKEEPSIE NY 12603 Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, i. e. a Wrap-Up Policy) 1 c. NYS Unemployment Insurance Employer Registration Number of Insured 1 d. Federal Employer Identification Number of Insured or Social Security Number 082563726 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) Town of Wappinger 20 Middlebush Rd. Wappingers Falls, NY 12590 3a. Name of Insurance Carrier Hartford Accident & Indemnity Co 3b. Policy Number of entity listed in box "1 a": 76 WEG TY3093 3c. Policy effective period: _09_/24/2007 ______ tp ___09/24/2008 _____ 3d. The Proprietor, Partners or Executive Officers are: ~ ^ included. (Only check box if all partnerslofficers II included) <II excluded or certain pcrtnersi~:ificers excluded . This certifies that the insurance carrier indicated above in box " 3" insures the business referenced above in box "18" fOr workers' compensation under the New York State Workers' Compensation Law. (TO use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices 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 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: _xathi Golowski_ ___ __ _ __ _ _ _ __ _ __ _ ___ (Print name of authorized representative or licensed agent of insurance carrier) Approved by: _V ~_Li (Date) Title: _Operations_Manager _________________ Telephone Number of authorized representative or licensed agent of insurance carrier: ~__ ~ ~ ~' ~ ~' ~ G ~ ~ ~ c~ Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2 (9-07) Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-07) Revised 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 845-279-2771 Premier Heating & Cooling, Inc. 155 Main Street lc. NYS Unemployment Insurance Employer Regi3ration Brewster, NY 10509 Number of Insured 1 d. Federal Employer Identification Number of Insured or Work Location of Insured (Only required if coverage is specifically Social Security Number limited to certain locations in New York State, i. e. a Wrap-Up Policy) I3-4104815 Same 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) National Grange Mutual 3b. Policy Number of entity listed in box "la": WCV78197 Town of Wappingers 3c. Policy effective period: 20 Middlebush Road 08/15/2007 - 8/15/2008 Wappingers Falls, NY 12590 3d. The Proprietor, Partners or Executive Officers are: ^ included. (Only check box if all partners/officers included) X 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 underthe 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 fisted above as the certificate holder in box " 2". The /nsurance Carrier will also notify the above certifrcate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days /F there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular 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 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 thenandatory 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: Michael H. Spain (Print name of authorized representa[ie or licensed agent of insurance carrier) • Approved by: (Signature) (Date) 12/04/2007 Title: President of Spain Agency Telephone Number of authorized representative or licensed agent of insurance carrier:(845) 628-4500 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-]05.2 (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 permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. 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 ofthe policy specify the states ofcoverage. 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 finding "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 fully covered under the NYS Workers' Compensation Law. [f 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 ofthis form, the U-26.3. Iftheout-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 Administratorwill send this form to the governmententity upon request). If an out-of-state employer does not meet any ofthe 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 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF PARTICIPATION IN WORKERS' COMPENSATION GROUP SELF-INSURANCE 1a. Legal Name and Address of Business Participating in Group Self- 1d. Telephone Number of Business referenced in box "la" Insurance (Use Street Address Only) Wilson Multi Power Oil, Inc. 845-831-4138 634 Route 52 Beacon, NY 12508 Member #850394 1e. NYS Unemployment Insurance Employer Registration Number of Business referenced in box "1a" 1b. Effective Date of Membership in the Group 9/10/1999 valid: 1 /1 /2006- 1 /1 /2007 78-91020 1c. The Proprietor, Partners or executive Officers are: 1f. Federal Employer Identification Number of Business referenced in Box X Included (only check box if all partners/officers included) "1a" ~7 All excluded or certain partners officers excluded 14-17112130 2. Name and Address of the Entity Requesting Proof of Coverage (Entity 3. Name and Address of roup a -Insurer Being Listed as Certificate Holder) TEAM Transportation Workers' Comp Trust Town of Wappingers C/O Consolidated Risk Service, Inc. 20 Middlebush Road 985 Old Eagle School Road Wappingers Falls, NY 12590 Suite #504 Wa ne, 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 "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 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: Jeffrey J. Bogacki (Print name of authorized representative of the Group Self-Insurer) Certified by: Title: Administrator 124, 2006 (Date) Telephone Number: GSI-105.2 (2-02) 10) 687-3869 Jail. STATE OF NEW YORK , `~~~IVE~ WORKERS' COMPENSATION BOARD AFB; `~ ~ - ...:~ CERTIFICATE OF PARTICIPATION IN WORKERS' COMPENSATION GROUP SELF-INSURANCE TOWN CLERK 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 36 Violet Avenue Poughkeepsie, NY 12601 le. NYS Unemployment Insurance Employer Registration Number of Business referenced in box "la" lb. Effective Date of Membership in the Group 04-57539 2 04/06/06 lc. The Proprietor, Partners or Executive Officers are lf. Federal Employer Identification Number of Business referenced in X included (only check box if all partners/officers included) Box "la" ^ all excluded or certain partners/officers excluded 14-1608318 2. Name and Address of the Entity Requesting Proof of Coverage 2, Name and Address of Group Self-Insurer (Entity Bein Listed as Certificate Holder) g 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 "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 "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: John M. Conroy (Print name of authorized representative of the Group Self-Insurer) Certified by: ~~ 7„ ~ 04/06/06 (Datel Title: Telephone Number: (518) 456-5557 GSI-105.2 (2-02) t MARSH December 28, 2006 Town of Wappingers 20 Middlebush Rd. Wappingers Falls, NY 12590 Subject: Kingston Oil Supply Corp. Certificate of N1'S Workers' Compensation Insurance To Whom It May Concern: JAN 1 1 2007 TOWN CLERK Please see the attached WC C-105.2 certificate of insurance evidencing coverage in place for the current policy period issued on behalf of the above captioned. We trust all is in order. However, should you have any questions please do not hesitate to contact us. Sincerely, ~~ r ~.~t...~~~1' -5~.. C`'_ Lashelda Bridgers Encl. ~~~ Lasltelda Bridgers Insurance Assistant Marsh USA Inc. 1 166 Avenue of the Americas New York, NY 10036 212 345 6195 Fax 2 ] 2 345 4853 ~a~ww.marsh.com 1..ashelda.I3ridgers;i%~marsh.com ~~~ a ~ zoos p ~~~; ~L)rrt;,=: r1;°FIC: ~tJ ~ _ n ~;~=„ ~~ ~OV'JI~ ~;~ A~JP„- E- ~f~.~a~. Marsh & McLennan Companies STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name and address of Insured (Use street address only) 1 b. Business Telephone Number of Insured KINGSTON OIL SUPPLY CORP. P.O. BOX 760 PORT EWEN, NY 12466 Ic. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically limited 1 d. Federal Employer Identification Number of Insured 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) NEW HAMPSHIRE INS. CO. TOWN OF WAPPINGERS 3b. Policy Number of entity listed in box K1a": 20 MIDDLEBUSH RD. WC 7207142 WAPPINGERS FALL5, NY 12590 3c. Policy effective period: 11/01/06 to 11/01/07 3d. Th Proprietor, Partr-ers or Executive Officers are: ~ , inCluded. (Only check box if all partners/officers included) ^ all excluded or certain partners/oflicets excluded. 3e. Demolition is: (Definition of Demolition on Reverse) ^ included. excluded. This certifies that the insurance carrier indicated above in box " 3" insures the business referenced above in box "I a" for workers' compensation under the New York State Workers' Compensation Law. (To use this fom~, NY must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The htsruance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be seat by regular mail.) Otherwise, this Certificate is valid for a maximum of oneyear 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 perj ury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the~e/rage as depi n this fo~. Approved by: l JI~-/~ /~ ~ 1-~<J ` /~ (Print name of authorized representative or licensed agent of insurance carter) Approved by: Title: Q Telephone Number of authorized representative or licensed agent of insurance carrier: X17 4S7 ~ ~ ~ ~ `'~ Please Note: Only ir:surance carriers and their licensed agents are authorized to issue the C-/05.2 form. Insurance brokers are NOT authorized to issue it. C-]05.2 (I2-03) 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 permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any genera] 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. C-105.2 (12-03) Reverse NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE KEEVILY,SPERO-WHITELAW INC. 500 MAMARONECK AVENUE HARRISON NY 10528 RECEIVED OCT 31 2005 TOWN CLERK •:•:•:•P.L~1Qt~:~E~31l~REf~>$Y>'TWIS:~IrLt~7'IF:~CA:TE~:~:~:~>:~:~:~:~:~: :::::::::::~:t:~:o~~rg~~:::~~:::tr:fat:~~~s ::::::::::::::::::::::::::: POL!CYHOLnER D SILVESTRI SONS INC 173 OLD ROUTE 9 SUITE 1 FISHKILL NY 12524 POLICY NUMBER G 1006 239-6 DATE 8/31/2005 CERTIFICATE NUMBER 276-125 CERTIF!CeTc NOL~ER TOWN OF WAPPINGER P 0 BOX 324 WAPPINGER FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1006 239-6 UNTIL 11/01/2006 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 11/01/2006 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WIi,L nE GIVEiY Tu THE CERTIFICATE iiOLDER ABOVE. IvuTiCE BY REGULAR HAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. U-26.3 THE STATE INSURANCE FUND ,tM Ct~ ~, lne~ rUw~:.,~~ DIRECTOR, INSURANCE FUND UNDERWRITING 25675 CERT02-2/2001 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS wnRKFlac~ r`nMDCAicwT~n~i ~.~~~ ~~,,.~,.~ ,....,, - -- --- - - - 1a. Legal Name and address of Insured (Use street ~.~.v~~wn u~.~VRr11Y~,C~.VVCKHGt 1b. Business Telephone Number of Insured address only) 845-486-5774 CENTRAL HUDSON GAS & ELECTRIC CORPORATION 284 SOUTH AVENUE 1c. NYS Unemployment Insurance Employer Registration POUGHKEEPSIE, NY 12601 Number of Insured Work Location of Insured (Only required if coverage is 1d. Federal Employer Identification Number of Insured or specifically limited to certain locations in New York Social Security Number State, i. e. a Wrap-Up Policy) 14-0555980 2. Name and Address of the Entity Requesting 3a. Name of Insurance Carrier Proof of Coverage (Entity Being Listed as the The Travelers Indemnity Company of America Certificate Holder) 3b. Policy Number of entity listed in box "1a": TOWN OF WAPPINGER TC2H-UB-281D196-0-07 20 MIDDLEBUSH ROAD WAPPINGER FALLS, NY 12590 3c. Policy effective period: 01-01-07 to 01-01-08 3d. The Proprietor, Partners or Executive Officers are: ® Included. (Only check box if all partners/officers included) ^ all excluded or certain partners/officers excluded. 3e. Demolition is: (Definition of Demolition on Reverse) ^ included. ^ excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "1 a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy ore/iminate the insured from the coverage indicated on this Certificate. (These notices maybe 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 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: JONATHAN P. TWISS (Print name of autphorized representative or licensed agent of insurance carrier) Approved by: I. <~~%u/'ZiJ~L // (Signature) (p ) Title: COUNT REPRESENTATIVE Telephone Number of authorized representative or licensed agent of insurance carrier: (315) 425-3944 ~~~~-~- -f.. Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insura ce brokers are NOT authorized to issue it. C-105.2 (12-03) W31 F2604 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof 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 finding "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 fully 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 W31F2B04 ~t~~ ~ NEW YORK STATE INSURANCE FUND ~`~ 1 WATERVLIET AVENUE XTE~iSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :::~1?E=€#ioa:~CO.r1~~Eb:~f3Y:~tWIS:~CI=€~'~IF:ECat~~:::~:::~:~::~: POLICYHOLDER MID HUDSON DEVELOPMENT CORP PO BOX 636 FISHKILL NY 12524 POLICY NUMBER +A 1317 868-6 DATE 12/24/2008 CERTIFICATE NUMBER 492-833 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1317 868-6 UNTIL 3/25/2009 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 3/25/2009 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~~~~~F~E~` ~~~~~,~~ p^t4_~~~~ THE STATE INSURANCE FUND ~~ U-26.3 DIRE R, INSURANCE FUND UNDERWRITING ci.~ ..~rT .... .. ........ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 5181 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :~:~:~i'?!=€#1f1f3:~Ei~.i/~R~b:~BY:~1WIfs>~~i~1`I~:IG;A~Cf ::~:~:~:~>:~:~: POLICYHOLDER BVM BUILDERS INC 924 SALT POINT TURNPIKE PLEASANT VALLEY NY 12569 POLICY NUMBER ''tA 1463 865-4 DATE 12/24/2008 CERTIFICATE NUMBER 461-447 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 1/13/2009. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. t ~' SEC ~ ~:' ~il~ THE STATE INSURANC~E~FU-ND CANCELLATION ~~'~'~ %~~~f~~'` U-26.3 DIRE OR, INSURANCE FUND UNDERWRITING 17S NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SION, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSIJRANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ::~:~f?C-~€21Qd:~CC3~R~d:~$Y:1'WI~:~C~Ft1l~:{GA~~ :~::~:~:~::::~: POLICYHOLDER MID HUDSON DEVELOPMENT PO BOX 636 FISHKILL CORP NY 12524 POLICY NUMBER +A 1317 868-6 DATE 12/24/2008 CERTIFICATE NUMBER 399-798 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1317 868-6 UNTIL 3/25/2009 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW, YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 3/25/2009 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~~~~~~ DEC t G .~~~ ~(~1/I.l~t r~.r~K U-26.3 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING L/.G NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSIJRANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :;::AC~E21QE3:~EC~1f~R~D:~$Y:~'THI~:~sr~€tTiK:EG;47f :~:~:~:~:::~::~: POLICYHOLDER MID HUDSON DEVELOPMENT CORP PO BOX 636 FISHKILL NY 12524 POLICY NUMBER +A 1317 868-6 DATE 12/24/2008 CERTIFICATE NUMBER 844-100 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS .FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1317 868-6 UNTIL 3/25/2009 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 3/25/2009 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~ ~~~~~ ~~~ SEC ~ ~ ~0~ 7'~~in' ~LCRK THE STATE INSURANCE FUND C~~ U-26'3 DIRE R, INSURANCE FUND UNDERWRITING Fi41 ,-.-r,~,,,, ,, ,, ,,,,,,, , NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~~~~~' ~~ TOWN OF WAPP INGERS DE~ / 4 ~QO~ ATTN: SHELLY 2U MIDDLEBUSH ROAD ~O~nl(~~ ~.~~~~ WAPPINGERS FALLS NY 12590 ~r :~:;::::i~~E21f~E>::GC3V~F't~ti::BY:~'i'WIC:~C~F2.TIF:EG~'C~~:~:~:::::~:::;:;::: POLICYHOLDER FLORIDA NORTH INC 125 CHARLESTON INDUSTRIAL PARK LN BLDG ~~5 ESPERANCE NY 12066 POLICY NUMBER +A 2022 334-3 DATE 12/19/2008 CERTIFICATE NUMBER 239-927 CERTIFICATE HOLDER. TOWN OF WAPPINGERS ATTN: SHELLY 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 1/08/2009. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTENB OR ALTER THE COVERAGE AFFORDED BY THE POLICY. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING 689 cTnr o ni- ~ i~ nn ~ ~~ STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name and address of Insured (Use street address only) 1b. Business Telephone Number of Insured 1-610-696-3900 Middle Department Inspection Agency Inc 1337 West Chester Pike 1c. NYS Unemployment Insurance Employer Registration Number of Insured West Chester, PA 19380-0904 Work Location of Insured (Only required if coverage is specifically 1 d. Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e. a Wrap-Up Policy) 222036075 2. Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) © SELECTIVE INSURANCE COMPANY OF AMERICA ^ SELECTIVE WAY INSURANCE COMPANY Town of Wappinger ^ SELECTIVE INSURANCE COMPANY OF SOUTH CAROLINA 20 Middlebush Road ^ SELECTIVE INSURANCE COMPANY OF NEW YORK Wappinger, NY 14568 3b. Policy Number of entity listed in box "1a": WC7241579 ~~~~0` ~~ 3c. Policy effective period: 11 V 01 /01 /2009 to 01 /01 /2010 ~ ~E~ ~ g ~~th 3d. The Proprietor, Partners or Executive Offices are: ~..^~A © 1nClUded. (Only check box if all partnerslofficers included) I 66 I/ II `` ~~~~f( ^ all excluded or certain partners/officers excluded. 3e. ~emOlltlOn IS: (Definition of Demolition on Reverse) ^ included. ® 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 /F a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for a maximum of one year after this form is approved by the insurance carrier or its licensed agent. ' Please Note: Upon the cancellation of 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: James F. Cuff, Jr. Approved by: Title: President & COO 12/ 19/2008 (Date) Telephone Number of authorized representative or licensed agent of insurance carrier: 1-800-872-1127 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 (Print name of authorized representative or licensed agent of insurance carrier) C-105.2 (9-01) Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any. general or special statute requiring or authorizing any, such contract, shall not enter into any such contract unless proof 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. C-105.2 (9-01) Reverse NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE FXTE~TSION, ALBANY, NEW YORK 12206-1649 (518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1317 868-6 DATE 12/09/2008 CERTIFICATE NUMBER 492-833 :: i?~E21~7E?::CC~\l~f~Eb:~BY: tHIS:~lr~€?TiF:FGi~7E::::::'::; POLICYHOLDER MID HUDSON DEVELOPMENT CORP PO BOX 636 FISHKILL NY 12524 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 12/29/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THI~ ~F~~)I°vpOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY i ~~11 TOWR! CLCRK ~ ~ ~ '~_ CANCELLATION TT-2h_'2 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE FXTE~I5ION, ALBANY, NEW YORK 12206-1649 (518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1317 868-6 DATE 12/09/2008 CERTIFICATE NUMBER 399-798 `::;1?~E21OC5:~CCl:V~RLD:: ~Y; tW15 `>r~Fi:1`I~:FC;47f :::::::::::::::::: :::;~~;2~:1~0o8:::F[~::~~:f29/~~~~::~ ::::::::::: POLICYHOLDER MID HUDSON DEVELOPMENT CORP PO BOX 636 FISHKILL NY 12524 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 12/29/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~~~ ~~~ CANCELLATION U - 26.'i ~CI/Ut~t ~~C~1~~ >~ .~` THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :::::::1?f=€21f)d::C011~1~~b>BY::TF15::E~R:~IF:IGA'f.~ :::::::::: ::::::;3.~2~:1 ~~03 :~Ta::~~.f291:~OD8:::~:::::~::::::::::: POLICYHOLDER MID HUDSON DEVELOPMENT CORP PO BOX 636 FISHKILL NY 12524 POLICY NUMBER +A 1317 868-6 DATE 12/09/2008 CERTIFICATE NUMBER 844-100 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 12/29/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. M {' .-_ ~ ; .k ~ i ~. r..... f((. ^~~a~~~€ i ~`. ~. :~,~ CANCELLATION TT-26.'i ~ ti THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD Z'(11n'~~ ~f_~--~~, POLICY NUMBER WAPPINGERS FALLS NY 12590 +A 1153 258-7 ;~ DATE ' 12/04/2008 ' ~ CERTIFICATE NUMBER 118-434 :.:.:.R~€?iQE3:~Ci~l~F~ED:~BY:~tH15:.>r~f~TIF:ICA~f :.:.:::~::::.: POLICYHOLDER CERTIFICATE HOLDER REHABILITATION SUPPORT SERVICES INC TOWN OF WAPPINGER 5172 WESTERN TPKE 20 MIDDLEBUSH RD ALTAMONT NY 12009 WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 12/24/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING R Fi NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORI{E~~ COMPENSATION INSURANCE ~~~~~~~~ ~~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD POLICY NUMBER T()UU~~ C~-~~~~ +A 1424 417-2 WAPPINGERS FALLS NY 12590 DATE 12/04/2008 r ~ "!> ~ CERTIFICATE NUMBER ° ;~ 348-067 ::,:::.R~#iQE3>COrIEi~~D:~81!:.THiS:~~3ir~R:tIF:1GR7'~ : :.:: >:::_: POLICYHOLDER SBI~CONSTRUCTION SERVICES INC 7 VETERANS PLACE WAPPINGERS FALLS NY 12590 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 12/24/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. CANCELLATION U-26.3 THE STATE INS U RANCE FUND ~~~ ~ j~ /~%l Q/f~E%~ DIRE OR, INSURANCE FUND UNDERWRITING pia CTI'll^ A A I '1 / 1 n /~ ~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN (518) 437~6400ANY, NEW YORK 12206-1649 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER ~~~~i~~~~ 20 MIDDLE BUSH ROAD POLICY NUMBER ~~~ ~' ~ '~3~i +A 1412 334-3 WAPPINGERS NY 12590 POLICYHOLDER KBCW CONSTRUCTION PO BOX 383 WALKER VALLEY COIN[!! CLERP~ A y t ::1?~€t7f1E3::CO.1t~R~DfD1':~1W1~>E~F~7'I~:EGA7'~ :::::`::: >:::; CO INC NY 12588 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLE BUSH ROAD WAPPINGERS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1412 334-3 UNTIL 2/16/2009 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 2/16/2009 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. THE STATE INSURANCE FUND ~~ U-26.3 DIRE OR, INSURANCE FUND UNDERWRITING 495 rFOTm_~i~nn ~ DATE 12/04/2008 CERTIFICATE NUMBER 604-754 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) lb. Business Telephone Number of Insured ANCHOR ELECTRIC INC 38 FOX ROAD HOPEWELL JUNCTION, NY 12533 lc. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, i.e., a Wrap-Up Policy) ld. Federal Employer Identification Number of Insured or Social Security Number 202774866 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) MSA GROUP/NGM INS CO TOWN OF WAPPINGER 3b. Policy Number of entity listed in box "la" 20 MIDDLEBUSH ROAD WCV53655 WAPPINGER FALLS, NY 12590 3c. Policy effective period 08/10/08 to 08/10/09 3d. The Proprietor, Partners or Executive Officers are Included. (Only check box if all partners/officers included) XX All excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box " 3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notes the above certificate holder within 10 days IF a policy is canceled due to nonpayment ojpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box " 3c ", whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insuranc~arrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: _Dawn Buckley 0 ~~~ (Print name of authorized representative or licensed agent of insurance carrier) (.,` Approved by: (Signature) Title: Licensed Agent/Sr. CSR o-~ .o~Gl,~ ~~. (Date) CC ~9~. Telephone Number of authorized representative or licensed agent of insurance carrier: 866-676-3849 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C'-IOS.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-07) www.wcb.state.ny.us Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous 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. ~ECEI V~ T~~yN CLERK C-105.2 (9-07) Reverse New York State Insurance Fund Workers' Compensation & DesaGiliry Benefits Specialists Since 1914 199 CHURCH STREET, NEW YORK, N.Y. 1 0007-1 1 00 Phone: (888) 997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE f~ECEI~E~ ~~~~~ NATIONAL MAINTENANCE, INC 183 SWEET HOLLOW ROAD OLD BETHPAGE NY 11804 POLICYHOLDER NATIONAL MAINTENANCE, INC j 183 SWEET HOLLOW ROAD OLD BETHPAGE NY 11804 I CERTIFICATE HOLDER TOWN OF WAPPINGER j !, 20 MIDDLEBUSH ROAD WAPPINGER FALLS NY ~~ POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE j DATE ', Z 1327 758-7 ~ 166800 11 /01 /2007 TO 11 /01 /2010 i 10/14/2008 ', THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1327758-7 UNTIL 11/01/2010, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 11/01/2010 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE DOES NOT APPLY TO THOSE JOB SITES WHICH ARE COVERED BY OTHER INSURANCE AND ARE SPECIFICALLY EXCLUDED BY ENDORSEMENT. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~av o ~ 200 TOWN CLERK 12590-0324 NEW YORK STATE INSURANCE FUND e~~ ~~ DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 888739280 NEW YORK STATU~TTE INSURANCE FUND 1 WATERVLIET AVENUE ~518)S4037~6400ANY, NEW YORK 12206-1649 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGER NY 12590 ~:::`•i?~iQE3'C011~RED:~f3Y: TF(IS>~~R:TI~:EC;4T~~:`•<:~":~":~: POLICYHOLDER SABATINI BUILDERS INC 614 SHANENDOAH RD HOPEWELL JUNCTION NY 12533 POLICY NUMBER +A 1432 339-8 DATE 12/22/2008 CERTIFICATE NUMBER 895-282 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD .WAPPINGER NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 1/11/2009. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THTS _CERTIFICATE DOES_NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~ ~~f ~ ~ ~,~~ ~,; FaL~ _ ,~ti ;' _ _ l J ~, CANCELLATION U-26.3 775 .~_ x ~ ~ _; ~ ~, THE STATE INSURANCE FUND G~~ DIRE OR, INSURANCE FUND UNDERWRITING cTnrnni_~i~nn~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 ~5>:~,~E~€iiaE~: CC3rt~R~D:~BY: tH15`~~€~T:I~:EGa~f :~:~:~:~:~:~:~::~: POLICYHOLDER ~ SABATINI BUILDERS INC 614 SHANENDOAH RD HOPEWELL JUNCTION NY 12533 POLICY NUMBER +A 1432 339-8 DATE 12/22/2008 CERTIFICATE NUMBER 955-872 CERTIFICATE. HOLDER TOWN OF WAPPINGERS 20 MIDDLEBUSH RD. WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 1/11/2009. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR. INSURANCE COVERAGE. UPON THE CERTIFICATE HOLDER.-THIS---CERTIFICA-T-E DOES-NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~,._ ~~~~~a~~~„r ~E ~` ~ _ ~~°tno~. F ,~, ~ ~;~ CANCELLATION U-26.3 81 THE STATE RANCE FUND INS U ~r/l/1'L /~ j~ l~% ~ DIRE OR, INSURANCE FUND UNDERWRITING STATE OF NEW YOKK ,, ` `.. a WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name S Address of Insured (Use street address only) lb. Business Telephone Number of Insured Jones Services Co., LLC 845-294-1010 23(1 Route 17A lc. NYS Unemployment Insurance Employer Goshen NY 10924 Registration Number oI' Insured 46-934685 Work Location of Insured (Only required ifcoverrtge isspecificaUy limited to certa/~1 locations in New York State, i. e., rr Wrap-Up ]d. Federal Employer Identification Number of Insured or Social Security Number Policy) 06-1442242 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) OHI Workers Compensation Trust Town of Wappinger 3b. Policy Number of entity listed in box "la" 20 Middlebush Rd Wappinger Falls NY 12590 3c. W555855 Policy effective period y t ~ °"' ~ . ~ ~ , ,, ,, ~~4 " 3d. 01/01/09 to __Ol/O1/]0 The Proprietor, Partners or Executive Officers are ~~ InClUded. (Only chick box if fill partners/officers inchided) "~~"tV~~~~~s , ~- ,~.- X all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box " 3" insures the business referenced above in box "l a" for workers' compensation under the New York State Workers' Compensation Law. ('I'o use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). `the Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certif cate holder in box " 2". The Insurance Carrier will also note the above certificate holder within 10 days /F a policy is canceled due to nonpayment of premiums w' within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated ort this Certrftcate. (These notices may be sent by regerlar mail.) Otherwise, this Certificate is valid for one year after t/ris form is approved by the insurance carrier or its lice~rsed agent, or until the policy expiration date listed in box "3c", wlrichever is earlier. Please Noie: 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. 7lnder penalty of perjury, I certify that 1 am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: __ _____William 1Cloc ___ ___ __-___...___-_ (Print name of authorized representative or licensed agent of insurance carrier) Approved by: Title: 12/8!08 (Hate) Telephone Number of authorized representative or licensed agent of insurance carrier: _518-877-8623 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-10.2. Insurance brokers are NOT authorised to issue it. (Signature) Vice President C-]05.2 (9-07) www.wcb.state.ny.us - 9T3 462 4494 TU 9188gg? 1 7E44s v~r P.~2 STATE OF NEW YORK WQRKERS' COMPENSATION BOARD CERT~F'~C,A,TE OF NYS WOR,r~ COMPENSATION YN'SI7RANC.E COVERAGE -------- ia. Legal Name & Address of Insured (Use street address only) 1b. Business Telephone Number of Insured i=airview Hearthside Distributors, LLC 68 Violet ,4venua 845-485-4033 Poughkeepsie, NY 12603 lc. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of insured (Orrlyreyrrired,~r~yerageiss~pcc{fjral~v ld. Federal Employer Identiflaation Number of Insure limited ro certatrd locatlo>fs br Nt`w York Skare, i.e., a Wrap.•jlp or Social Security Number Policy) d 80-025fi380 Z• Name and Address of the ,Entity Requesting Proof of Coverage (Entity Being I.lsted as the Certificate Flolder) Town of Wappinger 2L7 Mid~lebrush Road WapPingQrs Falls, NY 12590 RC~~~~~~ ~- DEG 1 Cs L~;;;o _ ~. . ~; ~'®WR! CLERK 3a. Name of insurance Carrier National Unian Fire Ins Ca of Pittsburgh, PA 3b. Policy Number of entity listed in box "la" WC 6971906 3c. Polley ei~eetive period 10/20/06 to 10/20/Q9 3d. The Proprietor, Planners or 1/xecutive Officel-s are Q included. (t)nlyehet:k box It all partners/olYicers iecladca) all excluded or certain partnersloffcers excluded. This certifies that the insurance carrjer indicated about in box "3" insures the business refl:rcnced above in compensation underthe New Yark,State Workers° Com on the IIVI~ t)I2MATION PAGE of~e workers' tam Pensatton I,aw, (To use this form, New York IV box "I a'' for workers' this C,ertlfieate of Insuranc P satlan insurance policy), The Insurance Farrier pu 9tsl9cen dunder,l~~m 3A e to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also notes the above certificate {colder within 1(1 days 1Fa paltey is cant agent well send within 30 days 1F there are reasons of indicated on this Certificate her than nonpayment afpre,nlurns that cancel the policy or el1m~natc the tn.~yd r t °fPrem&ims or (7Rese notices may be.t~t by regular mail) Otherwise, this Cer~cme ~ va/ldfor one year after this orm l'' aPP~ved by the i'nswrance carrier ar its licensed a en or until the a!' ex nation dare listed In b e f om the coverage Please Note: Upon the cancollatlon of the workers compensation pole ~ n P ' ox "3e'', whichever is earlrer. named on a permit, license or contract issued by a certfic$te holder the business must Certificate of W Y dicated on this forth, If the business continues to be coverage requirements of the Nets York State eskers' Componsatlon Coverage or atl~er authorized proof that the businesselsh omply,~~ wihh thermath a new Workers Compensation Law. ndatory Under penalty of perjury, l certify that f am An Authorized represeptatjve or licensed a nt of th ' above and that the named insured has the eovo~y~ as depicted on this form. I;e a Insurance carrier referenced Approved by: Andrea Brav ~=nrl[ name oPauthorl7,Ed rePreeentatlve qr [iq~d g$Cr1t of insurance carrler) Approved by; + ('igna use) l ~ -" ~"~ Title: Marlaaer (hate) Telephone Number of authorized represa,tative or licensed agcni of insurance carrier: 8D0-845-2258 Please Note; Only insurance carriers and their /icensed agents ar¢ authorised to issue Form C- outhorized to i.r.4ue it. lOS.2. Insurance brokers are NOT C-105.2 (9-07) www.wcb.~ate,ny,us ~+'~F! T('iTGi Ps=irF . Gir N:>k NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSIGN, ALBANY, NEW YORK 12206-1649 ~518I 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1320 034-0 DATE 12/08/2008 CERTIFICATE NUMBER 202-771 ............................................................... ~: ~::::::>7C€21QE5::CC3V~f~~1?:~BY::'1'WIC::C~F~'I~:ECA'~f :::::::::::::::::::: POLICYHOLDER HARMAN CONSTRUCTION LLC 151 PINE RIDGE DR HOPEWELL JUNCTION NY 12533 CERTIFICATE HOLDER TGWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 12/28/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICA'PE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTENB OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~-~«, ~, .K°,., ~ ~ ,~` ~--.. _ ~ ~ CANCELLATION U-26.3 ~~~ ~~~ THE STATE F ND INS RANC E U U ~~~ ~ ~ , ~ ~ ` ~~%(Q/1~E~iIi` DIRE OR, INSURANCE FUND UNDERWRITING 1217 sTnraN-~i~nni NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~T$ION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BLDG DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY POLICYHOLDER BOVEE CONSTRUCTION CO INC 1732 MAIN ST PLEASANT VALLEY - NY 12569 12590 POLICY NUMBER +A 1334 840-4 DATE 12/08/2008 CERTIFICATE NUMBER 296-111 :~;:~p~€2iQE3:~6~3S1~t~~b:~$~!:~'1'HtB:~C~E~.1'IF:~C.It'~ :~:~:~:~:~:~:~:~:~: CERTIFICATE HOLDER TOWN OF WAPPINGER BLDG DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1334 840-4 UNTIL 9/17/2009 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 C&ANGED PRIOR TO 9/17/2009 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 Tiv'SURANCE COVERAGE UPON THE CERTIFICATE HOLDER. TIiIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. U-26.3 ~ ~ ,~' -~- ~° ~~~~ G~~~~ THE STATE INSURANCE FUND ~~ DIRE R, INSURANCE FUND UNDERWRITING 1147 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~` TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1320 034-0 DATE 12/08/2008 CERTIFICATE NUMBER 942-70(i :«•P.~Ei1Qd>CC311~R~b:~~`~:~'i'H15:~C~F2~'1~:{CA'tE<~:~:~:~:~:~:~;:~: POLICYHOLDER HARMAN CONSTRUCTION LLC 151 PINE RIDGE DR HOPEWELL JUNCTION NY 12533 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE .THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 12/28/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ,~ ~ CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~~ 1f/ ~ ~~Ei~ DIRE OR, INSURANCE FUND UNDERWRITING 487 STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 :•:~:•P.~tiQEi:~EC3.~~~f;:~SY:~.T.H15:~C~€t~l>=:ECaT~~:~:~:~:~:~:~:~:: ~: :~:~:~:~:~~~2X1~~~0:~:~:~~~1:~:~:~~~fZf~f~00~ ~:~:~:~:~:~:~:~:~:~:~:~:~: POLICYHOLDER REHABILITATION SUPPORT SERVICES INC 5172 WESTERN TPKE ALTAMONT NY 12.009 POLICY NUMBER +A 1153 258-7 DATE 12/08/2008 CERTIFICATE NUMBER 118-434 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1153 258-7 UNTIL 7/20/2009 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 7/20/2009 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. ~~~~ ~~ DEC A ~ ~~'... ,~;~ THE STATE INSURANCE FUND U-26.3 ~~ DIRE R, INSURANCE FUND UNDERWRITING 1469 CERT02-2/2001 1'-'\ • `i , STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier la. Legal Name and Address of Insured (Use street address only) lb. Business Telephone Number of Insured My Way Home Improvements Inc 845-226-1461 83 Brandy Lane 1 c. NYS Unemployment Insurance Employer Registration Wappingers Falls, NY 12590 45353264 1 d. Federal Employer Identification Number of Insured or 223695501 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Zurich Insurance Town of Wappinger 3b. Policy Number of entity listed in box "la": 20 Middlebush Road 17204471 Wappingers Falls, NY 12590 3c. Policy effective period: 04/01/08 04/01/09 to 4. Policy covers: a. ®All of the employer's employees eligible under the New York Disability Benefits Law b. ^ Only the following class or classes of the employer's employees: Under penalty of perjury, I certify that I am an authorized representative or lic nt the ' ur a ca ier referenced above and that the named insured has NYS Disability Benefits insurance coverage as des ibed a ve. ~~ Date signed 9/11/08 By Timothy E Dean ~` (Signature of insurance carrier's authorized represen tiv or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 845-454-0800 Title Authorized Representative IMPORTANT: if box "4a" is checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier, this certificate is COMPLETE. Mail it directly to the certificate holder. If box "4b" is checked, this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed for com letion to the Workers' Com ensation Board, DB Plans Acc lance Unit, 20 Park Street, Alban ,New York 12207. PART 2. To be com leted b NYS Workers' Com ensation Board Onl if box "4b" of Part 1 has been checked) State Of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation Board, the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date Signed By (Signature of NYS Workers' Compensation Board Employees) Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Fortn DB-120. I .Insurance brokers are NOT authorized to issue this form. r. ";;; ~ ~-~ , wp„~®~ ~~ ,o DB-120.1 (5-06) Additional Instructions for Form DB-120.1 By signing this form, the insurance carrier identified in box " 3" on this form is certifying that it is insuring the business referenced in box "la" for disability benefits under the New York State Disability Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box "2". This Certificate is valid for the earlier of one year after this form is approved by the insurance carrier or its licensed agent, or the policy expiration date listed in box " 3c ". Please Note: Upon the cancellation of the disability benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of NYS Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law. DISABILITY BENEFITS LAW §220.Subd.8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article, and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. DB-120.1 (5-06) Reverse NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISIGN, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLE BUSH ROAD WAPPINGERS NY 12590 '®~r ,~ ~ c2~0~ T ~~~ CLERK :~>:~f?E~2it~fi:~EOSI~I?ED:~$1!:~1HIS:~IrC-€tTIF:EC~T~~:~:~:~:~:~:~:~': POLICYHOLDER KBCW CONSTRUCTION CO INC PO BOX 383 WALKER VALLEY NY 12588 R~~~e ~~ D POLICY NUMBER +A 1412 334-3 DATE 12/01/2008 CERTIFICATE NUMBER 604-754 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLE BUSH ROAD WAPPINGERS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 12/21/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING 481 STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER BLDG DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 n~~~~~~~ DEC ~ w~ ?gyp ~C1/V(~ CLERK POLICY NUMBER +A 1334 840-4 DATE 12/01/2008 CERTIFICATE NUMBER 296-111 :~:~:~i2~€tiQf>:~C01/~R~b:~81!:~tW1~:~C~€~TI~:{Gate :~:~:~:~:~::~:~: POLICYHOLDER BOVEE CONSTRUCTION CO INC 1732 MAIN ST PLEASANT VALLEY NY 12569 CERTIFICATE HOLDER TOWN OF WAPPINGER BLDG DEPT 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 12/21/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS PiOR INSURANCE COVERAGE UFON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. CANCELLATION U-26.3 925 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING STDCAN- 2/2001 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name and address of Insured (Use street address only) lb. Business Telephone Number of Insured (845) 485-4033 Fairview Hearthside Distributors LLC 68 Violet Avenue lc. NYS Unemployment Insurance Employer Registration Poughkeepsie, NY 12603 Number of Insured APPLIED FOR Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, i.e. a Wrap-Up Id. Federal Employer Identification Number of Insured or Policy) Social Security Number 80-0256380 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) AIG 3b. Policy Number of entity listed in box "la": TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WC 006-97-1906 WAPPINGERS FALLS, NY 12590 3c. Policy effective period: 10/20/2008 to 10/20/2009 3d. The Proprietor, Partners or Executive Officers are: X ~~ Included. (Only check box if all partners/officers included) "all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box " 3" insures the business referenced above in box "1 a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notes the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent or until the policy expiration date listed in box "3c", whichever is earlier.. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers': Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Approved by: Title: (Print name o 'zed r iv or li nsed dent of insurance carrier) t~-~z~o~ (Signature) (Date) President Telephone Number of authorized representative or licensed agent of insurance carrier: (845)471-6200 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2 (9-07) ~~~~~ - Workers' Compensation Law ,. ~- ~~~~ GLe~ Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-07) Reverse NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE ~51$)54~7-6400ANY, NEW YORK 12206-1649 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE R~C~~~ E~ '~"~ TOWN OF WAPPINGER NpV ~ ~ )~~~ 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 TOwN CrLfCRK ::::::;::R~E#1~iE3::E~3Y~R~~3::$Y:~1'WIg::C~1'I~:EC~k'{~:::::::>::::"::: POLICYHOLDER HARMAN CONSTRUCTION LLC 151 PINE RIDGE DR HOPEWELL JUNCTION NY 12533 POLICY NUMBER *A 1320 034-0 DATE 11/10/2008 CERTIFICATE NUMBER 942-706 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1320 034-0 UNTIL 4/22/2009 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 4/22/2009 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. THE STATE INSURANCE FUND ~~ U'26.3 DIRE R, INSURANCE FUND UNDERWRITING CERT02-2/2001 397 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER R~C~~V~ 20 MIDDLEBUSH ROAD ,~ WAPPINGERS FALLS NY 12590 ~oV ~ l2QQ~ T OWN C~FRK ~: ~:;"PL~21QE3:~E~31t~f~~I~::B`~::~'WIC:~E~E~1'I~:fGA'F~:::::"::::`::::: POLICYHOLDER HARMAN CONSTRUCTION LLC 151 PINE RIDGE DR HOPEWELL JUNCTION NY 12533 POLICY NUMBER *A 1320 034-0 DATE 11/10/2008 CERTIFICATE NUMBER 202-771 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1320 034-0 UNTIL 4/22/2009 COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORR WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 4/22/2009 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COt4PLIANCE WITH THIS PROVISION. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. THE STATE INSURANCE FUND ~~ U'2G.3 DIRE R, INSURANCE FUND UNDERWRITING 409 CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~ECEt 1/E~ ~~ TOWN OF WAPPINGERS dC ~ ~ ~ °t~~t 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 T~WIV CLERK :~:~1?~Ei1QE)>EOil~E3~d>f3Y:~1Ht5:~~~€fi1`I~:~C:4~'~~: >:~>:<~::: POLICYHOLDER STANFORD BUILDERS INC P 0 BOX 179 STANFORDVILLE NY 12581 POLICY NUMBER +A 1475 482-4 DATE 10/21/2008 CERTIFICATE NUMBER 230-277 CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 11/10/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. THE STATE INSURANCE FUND CANCELLATION ~~~- %~~ U-26.3 DIRE OR, INSURANCE FUND UNDERWRITING NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER ~~~~O~~L.J POLICY NUMBER 20 MIDDLEBUSH ROAD (~~ r +A 1375 334-8 WAPPINGERS FALLS NY 12590 ~ ~ z0o~ DATE ]'Q~~ 10/17/2008 CLERK CERTIFICATE NUMBER 879-730 :~AERIQE~:~EO.'ifGR~D: $Y: tH15:~O~R:TIF:IC:AtE :~:::::::~: :::::~~:031;2~~~:~~::~r fah:l~Q08::~:~:::::::::: POLICYHOLDER PACE BUILDERS OF DUTCHESS INC 1327 NOXON RD LAGRANGEVILLE NY 12540 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 11/06/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING ~~~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE EXTENSION, ALBANY, NEW YORK 12206-1649 (1518)) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~ECEiv E® OCT 2 4 2008 TOWN CLERK :~:.:.:.P~€2iQb:.EC7:~REd:.8Y:.1W1~:`•~~E2"fI~:FG~4~f::.>:_:.: »:::.: POLICYHOLDER AMODEO CONTRACTING INC PO BOX 72 BILLINGS NY 12510 POLICY NUMBER +A 1457 834-8 DATE 10/20/2008 CERTIFICATE NUMBER 589-094 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 11/10/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING 731 STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 199 CHURCH STREET NEW YORK N.Y. 10007-1100 1-8$8-997-3863 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 RECEi~I'~~~ OC 1 ~ ~ LD~V TOVIFN CLERK ~: ~::::`1?C,€t1QE1: ~ECIl~R~~::SY: ~ 1'WIC::lr~t~TI~:FGAT~:S»::>:::::::`•: POLICYHOLDER DEW CONSTRUCTION INC P 0 BOX 420 PATTERSON NY 12563 POLICY NUMBER +G 1015 947-3 DATE 10/20/2008 CERTIFICATE NUMBER 463-912 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 11/10/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING 2151 STDCAN-2/2001 NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (914f 701-2120 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FLS NY 12590 ~: ~::::::1?~€2fQa:: Cd1f~ Rid:: f3`!: ~'TWt~: ~ iv~t~71~:1C.A*~::: ` ::::::::::::::: ~~::»:.:~.~;2~ 1 ~~>'~8:~'1~::~yf 261 ~Q4~ :::::::::::::.:.:.:.::: POLICYHOLDER MARKAT CONSTRUCTION CORP. T/A T & M CUSTOM BUILDERS 116 COLANDREA ROAD EXT NEWBURGH NY 125501074 POLICY NUMBER +W 1198 312-9 DATE 11/06/2008 CERTIFICATE NUMBER 164-751 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 11/26/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. RECEIVE NOV 1 i ~ ~~~ ~~... TOWN CLERK CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING ~rj~ cTnreni_oi~nn~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE SION, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER 2U MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1448 745-8 DATE 11/04/2008 CERTIFICATE NUMBER 175-923 ~:~::::::i~lE2f<aE3:: C~.V~~~D::~Y: ~ 1'WI~<C~t~fi'l>":GGA'i~ :::::::::::::::::::: :::::::::~~z~:~~~a~:::~~::~r:tz~f:~oo~ ::::::::::::::::::::::::::: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 11/24/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED EY THE POLICY. RECE~~~. N0~ 1 1 2t1~ TOWN CLERK CANCELLATION U-26.3 667 THE STATE INSURANCE FUND ~~ DIRE OR, -NSURANCE FUND UNDERWRITING STI~CAN-9l~n(11 NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE~904S WO1T212QAIN5, NEW YORK 10604-3814 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE '~'~~ TOWN OF WAPPINGER MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 ::.:_:.PC~iic~E::6C711~REd$Y 7Wi~::~~€t1IF:EGat~ .:.:.:.:.:.:.:.:::.: POLICYHOLDER MARKAT CONSTRUCTION CORP. T/A T & M CUSTOM BUILDERS 116 COLANDREA ROAD EXT NEWBURGH NY 125501074 POLICY NUMBER +W 1198 312-9 DATE 11/06/2008 CERTIFICATE NUMBER 980-709 CERTIFICATE HOLDER TOWN OF WAPPINGER 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 11/26/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. RECEIVEC~ Nov ~ t aoo~ CANCELLATION U-26.3 TOWN CLERK THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING ,~.n 1 cTnr nni-7 /inn ~ NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE~904f 701T212QAINS, NEW YORK 10604-3814 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +W 1198 312-9 DATE 11/06/2008 CERTIFICATE NUMBER 936-553 ~':.::.PCB€2iQb>COrI;=aECi$~l:..T:Wifi:. C~E~7~IF:EGat~::.:.:.:.»:.:_: ::::::::1.;rz3:1 ~~~~':::~'~:::~y.f26f:~~0~ :::::::::.:::.:::::::::.:.: POLICYHOLDER MARKAT CONSTRUCTION CORP. T/A T & M CUSTOM BUILDERS 116 COLANDREA ROAD EXT NEWBURGH NY 125501074 CERTIFICATE HOLDER TOWN OF WAPPINGER 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 11/26/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. RECEIVE Nov ~ ~ zoos CANCELLATION U-26.3 TOWN CLERK THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING ~h 1 cTnr n ni_n inn ~ NEW YORK STATU~TTE INSURANCE FUND 1 WATERVLIET AVENUE ~5i81S4~N!6400ANY, NEW YORK 12206-1649 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ TOWN OF WAPPINGER BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER +A 1448 745-8 DATE 11/04/2008 CERTIFICATE NUMBER 526-941 ~: ~:.:.:.p~iQE~:~EC3.rf~R~l?:. $~:. mHl~:. Chi#7'I~:FGik'f~ .:.:.:.:::::.:.: ::::::::~~z~~~~~s:::~~:::~r:tz~E~ao..~ :::::::::::::::::.::::::::: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 CERTIFICATE HOLDER TOWN OF WAPPINGER BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 11/24/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT APiEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. RECElVEC~ NQV ~ ~ 20A~ CANCELLATION U-26.3 ~OWIV CLERK THE STATE INSURANCE FUND l~~ DIRE OR, INSURANCE FUND UNDERWRITING 663 STDCAN-2/2001 NEW YORK STATE INSURANCE FUN® 1 WATERVLIET AVENUE XTE SIGN, ALBANY, NEW YORK 12206-1649 ~518~ 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~ WAPPINGERS FALLS BUILDING DEPARTMENT 2C MIL'JLEBUSH ROAD WAPPINGERS FALLS NY 12590 ~: ~::::::p~€i1Qti:: GC3l~R~b::9~!::'I'HIS:~C~Ft~'I~:FG~k'i'f;::::::::>:::;::: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 POLICY NUMBER +A 1448 745-8 _ DATE 11/04/2008 CERTIFICATE NUMBER 174-621 CERTIFICATE HOLDER WAPPINGERS FALLS BUILDING DEPARTMENT 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 11/24/2008. THIS INFORMATION IS FURNISHED YOU. IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. F~ECEIV~C~ T®VUN CLERK CANCELLATION U-26.3 THE STATE INS~Uj~RANC,E~FU`ND DIRE OR, INSURANCE FUND UNDERWRITING 677 STDCAN-2/2!701 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE ~518~54~7~6400ANY, NEW YORK 12206-1649 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE '~~ TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 ~: ~:.:.:, f~~2i1~t~:~EC3.rt~~~b:.8~`1~H15:~C~i1fi1F:ECa.:.:.> :.:.:.:.:.:.: POLICYHOLDER MAURICE E WILKINS DBA MW POOLS PO BOX 126 CLINTONDALE NY 12515 POLICY NUMBER +A 1448 745-8 DATE 11/04/2008 CERTIFICATE NUMBER 368-565 CERTIFICATE HOLDER TOWN OF WAPPINGERS FALLS 20 MIDDLEBUSH RD WAPPINGERS FALLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 11/24/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT A,*fEND, EXTEND OR ALTER THE COVERAGE AFFORDED EY THE POLICI'. ~EV~~U~~ ®~ ~ ~ ~~~~ TOWN CLERK CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING 647 ~TnraN-~i~nn ~ NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~ISION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~:~i?~€iiQd:~EC31t~~~b:~$Y>'CWI~:~~~f{7I~:FC;a7f~»:~:~>:~:~:: POLICYHOLDER HARMAN CONSTRUCTION LLC 151 PINE RIDGE DR HOPEWELL JUNCTION NY 12533 CERTIFICATE HOLDER POLICY NUMBER +A 1320 034-0 DATE 11/05/2008 CERTIFICATE NUMBER 942-706 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 11/25/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. ~~C~B!/~~'~ SOWN CLERK CANCELLATION U-2b.3 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING 5L~1 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE XTE~TSION, ALBANY, NEW YORK 12206-1649 518) 437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 POLICY NUMBER ''~A 1375 334-8 DATE 11/05/2008 CERTIFICATE NUMBER 879-730 :~:~:~RC~€2iQd:~CC3rf~R~Ci:~BY>1WIC:~ir~€~TI~:EGa7~~:~>::~:~>::~:~: :~:~:~:~:f:~:OBI:2~0~~~:~~1~:~:~:~y:f03f~~~0~ ::~:~::~:~:~:~:~::~:: POLICYHOLDER PACE BUILDERS OF 1327 NOXON RD LAGRANGEVILLE DUTCHESS INC NY 12540 CERTIFICATE HOLDER TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE STATE INSURANCE FUND UNDER POLICY N0. 1375 334-8 UNTIL 1/03/2009 , COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORK- ERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 1/03/2009 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NOV ~ T 20~1~ TOWfV CLERK THE STATE INSURANCE FUND U-26.3 ~~ DIRE R, INSURANCE FUND UNDERWRITING ~~p CERT02-2/2001 NEW YORK STATE INSURANCE FUND 1 WATERVLIET AVENUE FXTE~TSION, ALBANY, NEW YORK 12206-1649 11518)) 437-6400 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGER 20 MIDDLEBUSH ROAD WAPPINGERS FALLS NY 12590 :~:?~RE€21QE3:~C0.1t~R~D:~$Y:~?H15:~CE=€~1`I~:-C;A7f :~:~:~:~:~:~::~:~: POLICYHOLDER HARMAN CONSTRUCTION LLC 151 PINE RIDGE DR HOPEWELL JUNCTION NY 12533 POLICY NUMBER +A 1320 034-0 DATE 11/05/2008 CERTIFICATE NUMBER 202-771 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 11/25/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDEi) BY THE POLICY. ~~~ ~p~, ~~~ ~ ~f ~/j)~1~ ~~' -l/ Y. c~~~'~r CANCELLATION U-26.3 THE STATE INSURANCE FUND ~~ DIRE OR, INSURANCE FUND UNDERWRITING SRS cTn~nn~_~i•fnn~ NEW YORK STATE INSURANCE FUND 105 CORPORATE PARK DR, STE 200 WHITE PLAINS, NEW YORK 10604-3814 (9145 701-2120 CANCELLATION OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FLS NY 12590 RECEIVE OCT 1 ~ 2008 TOWN CLERK :~>PC€ifQd'6~.1f~R~d:~BY:~'CWII:~Ir~RTI~:IG:;4~~ :::~:~:~:~::~:~: POLICYHOLDER MARKAT CONSTRUCTION CORP. T/A T & M CUSTOM BUILDERS 116 COLANDREA ROAD EXT NEWBURGH NY 125501074 POLICY NUMBER +W 1198 312-9 DATE 10/08/2008 CERTIFICATE NUMBER 164-751 CERTIFICATE HOLDER TOWN OF WAPPINGERS BUILDING DEPARTMENT 20 MIDDLEBUSH RD WAPPINGERS FLS NY 12590 THIS IS TO ADVISE THAT THE WORKERS' COMPENSATION POLICY ISSUED TO THE POLICYHOLDER NAMED ABOVE HAS BEEN CANCELLED EFFECTIVE 10/28/2008. THIS INFORMATION IS FURNISHED YOU IN COMPLIANCE WITH TERMS OF THE CERTIFICATE OF INSURANCE NUMBERED AS ABOVE AND ANY OTHER CERTIFICATE OF INSURANCE PREVIOUSLY ISSUED TO YOU AT THE POLICYHOLDER'S REQUEST UNDER THE ABOVE POLICY NUMBER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. THE STATE INSURANCE FUND CANCELLATION U-26.3 ~~ DIRE OR, INSURANCE FUND UNDERWRITING .,~, IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. h~.vrcv to ~tuu iiua) ~rM INS0251o~oa>.o~ Page 2 of 2 ACORD CERTIFICATE OF LIABILITY INS R D ) ,~ ANCE U 8/31/20 0 PRODUCER (260) 482-5455 FAX: (260) 483-6297 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION STAR Insurance - Diller-Smith Office ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 2526 Scotsmolde ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 8517 Fort Wayne IN 46898 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: GREAT AMERICAN ASSURANCE 26344 ROAD RUNNERS CLUB OF AMERICA INSURERB:NATIONWIDE LIFE INSURANCE 70750 AND ITS MEMBER CLUBS INSURER C: 1501 LEE HWY, SUITE 140 INSURER D: ARLINGTON VA 22209 INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. A R AT WN MAY HAV BY I INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE _ POLICY NUMBER DATE MM/D DATE MM/DD LIMIT S GENERAL LIABILITY n~ EACH OCCURREN E $ 1 , 000 , 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence 300 OOO $ ~ A CLAIMS MADE ~ OCCUR MA00000568960002 12/31/2006 12/31/2007 MEDEXP An one erson $ 5,000 X LEGAL LIAB TO PART. 12:01 AM 12:01 AM pERSONALBADVINJURY $ 1,000,000 $1,000,000 GENERAL AGGREGATE $ NONE GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 1 , OOO , O OO O POLICY JEC T LOC AU TOMOBILE LIABILITY COMBINED SINGLE LIMIT E id t $ 1 , 000 , 000 ANY AUTO a acc en ) ( A ALL OWNED AUTOS MA00000568960002 12/31/2006 12/31/2007 BODILY INJURY SCHEDULED AUTOS 12 : O1 AM 12 : O1 AM (par person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN $ AUTO ONLY: AG $ E%CESSIUMBRELLA LIABILITY H RR N $ OCCUR ~ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETE :T d WORKERS COMPENSATION AND ' T RY TATIT- OTH- EMPLOYERS LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE $ If yes, describe under P IAL PR VI N below E.L. DISEASE -POLICY LIMIT $ B OTHER EXCESS ACCIDENT 6 SPX0000002408400 12/31/2006 12/31/2007 ExCESSt~DiCAL: $10,000 MEDICAL 12:01 AM 12:01 AM $250 DEDUCTIBLE: PER CLAI AD 6 SPECIFIC LOSS $2, 500 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER IS NAMED A3 AN ADDITIONAL INSURED A3 RESPECTS THEIR INTEREST IN THE OPERATIONS OF THE NAMED INSURED. DATE 6 EVENT: 09/16/07 DUTCHESS COUNTY CLASSIC ROAD RACES INSURED CLUB: MID-HUDSON ROAD RUNNERS, ATTN: VINCE VELTRE; 7 MERRICK ROAD; POUGHREEPSIE, NY 12603 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 09/16/07 TOWN OF WAPPINGERS FALLS EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ATTN : CONSTANCE SMITH 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT 20 MIDDLEBUSH ROAD FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE WAPPINGERS FALLS , NY 12590 INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATNE John Lefever/JRM ACORD 25 (2001/08) IMen~s ~~,~a~ moo, ©ACORD CORPORATION 1988 09-84-'87 07;57 FROM-Dewit Insurance Agen 845534319 T-900 P001/881 F-335 ACORDrM CERTIFICATE aF LIAE3ILITY INSURANCE DATEIMMIpOnwvl 08/30/2007 'ROOUGER THIS CERTIFICATE 13 ISSUED A9 A MATTER OF INFORMATION DEWITT 8 ELLIS AGENCY, INC. ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE CIO H.R. KELLER 8 CO„ ING, HOLDER. THIS CERTIFICATE DOES NOT AMENC EXTEND OR 1520 SHERIQAN bRIVE ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 8UFFALO, NY 14217 INSURERS AFFORDING COVERAGE NAIC IF V6URE0 .....___ . _. . DUTCHE55 COUNTY DEMOCRATIC COMMITTEE INSURER B: Al PAGE PARK DR. wsuRERC: POUGHKEEPSIE, NY 12601 INSIJRERD: CO. OVERAGES - THE POLICIES DF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABDVE FOR THE POLICY PERIOD INDICATED. N0TIMTHSTANOINO ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN L: SUBJECT TO ALL THE TERMS, EXCLUSIONS ANp CONDITIONS OF SUCH POLICIES. AGGRFGATF 1 IMITS SHAWN luau wa~ic ReeN R oro Inen nv eeln nI ewe. POLICVNUM6ER uCV i P ICYEXPIRA LIMIT 5 A X GENERAL l1ABILITY EACrIOCCURRENCE S 1 000 000 X COMMERCIAL GENERALUAp41TY L7205B99 3-10-2007 3.10.2008 pREM1~FC F.gflMb/F~PP S 50,000 CLAInnS`wiADE O OCCUR MEDEXP M oneDevsen) Y ~ QQQ PER 50NAL$ADVINJURY s EXCLUDED GENERAL AGGREGATE aT ~ 000 000 GEN'LAGGRfGgTEUMITAPPLIESPER: PRO PRODUCTS~COMP/OPAGG 6 EXCLUDED S LOC POLICY AUT OMOBILB LIAl~aITY eaB~~ SINGLE LIMIT l Z ANYAU70 E All OWNED AUTOS BODILY INJURY S SCHEDULEDAUTO$ (Paporcon) HIRED AUTOS $ODILY INJURY f NON~OWNEDAUTOS Ipaeccltlontl PROPERTY DAMAGE ~ fPSr aeemenll OARAGEUABtIITV AUTOONLY~a'!AACC{DENT S ANY AUTO OYHERTHAN CAACG S AV700NLY: AGCr ii EKCE86lUMBRELLA LIABILITY EACH OCCURRENCE 6 oCCUR ~ CLAIMSMADE AGGREGATE _ 9 DEDUCTIBLE S RETENTION 5 S WORHERS COMPENSATION AND u~ o HI EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER~XECUTIVE E.L. EACH ACCIDENT 6 OFfICERlME M9ER EXCLUDE07 It 4 ib d E.L. DISEASE~EA EMPLOYEE S yes. esCf i~n e7 S S S EGAL PROVI ION bainw E.L. DISEAStr~pOLICYLIMIT 8 OTHER )EBC RIPTION OF OPERATIO NB I l0 CATIONS I VEW CL E9! EKGLU910N8 ADDED RV FHYIOR9FME NT I APE©u_ PwMn~a n uw POLITICAL CAMPAIGN HEADQUARTERS FFECTIVE SEPTEMBER 8, 2007 THE CERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED :ERTIFICATE HOLDER CANCELLATION SHOULD ANV OP THE aeoveOE8CRBED POLICIES BE CANCELLED BEFORe THE EzPIRATION DATE THEREOF, THE 15suINa INSURER WILL ENDEAVOR TO MAIL ~ 5 oav8 WRITTEN ALSO LISTED AtiS' ADDITIONAL INSURED: NOVICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 91JT FAILURE TO DO SO SHALL UNIVERSITY SETTLEMENT IMPOaE NO 06LIOATION OR LIABILITY OP ANY RlrvO UPON THE INSURER ITS AGENTS OR 724 WOLCOTT AVENUE REPRESENTaTlvars. BEACON, NY 1508 AUTHOgIiW RC~REiENTATNE ~~^~~ >.CORD 25 (2001!08) ' ACORO CORPORATION 1988 08-30-'87 13;54 FPOM-Dewit Insurance Agen 8455343819 I'1YV/l~tM CERTIFICATE OF LIABILI 'ROOUCeR DEWITT & ELLIS AGENCY, INC. CIO H. R. KELLER 81 CO., INC, 1520 SHERIDAN DRIVE BUFFALO, NY 14217 V8URE0 DUTCHESS COUNTY DEMOCRATIC COMMITTEE 41 PAGE PARK DR, POUGHKEEP6IE, NY 12601 :OVERAGES T-889 P001/001 F-292 TY INSURANCE DATE (MMrotlnYYV) 08/30/2007 THIS CERTIFICATE IS ISSUED A3 q MATTER OP INFORMATION ONLY AND CONKERS NO RIGHTS UPON THE CERTIFICATE O H AL TER THE COVERAGE AFFORDED BY THE POL~CIES BELOW. INSURERS AFFORDING COVERAGE NAIC4 INSURER A: UNITED NATIONAL INSURANCE CO, 13084 IN SURER B: INFa1RERC INSURER D: INSURER E: Inc ~uLn:[ca ur IrvsuKANL'E LISTED BE40W HAVE BEEN 188UED Tp THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANOIN~3 ANY REQUIREMENT, TERM OR CONDITION OF ANV CONTRACT OR OTHER bOCUMENT WITH RESPECT Tq WHICW THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, 7HE INSURANCE AFFORDED BY THE POLICIES OE3CRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLU31oN$ AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANKS. L POUCVNUMBER CYEFF tlLl wRA710N LIMITS GENERAL 41A81UTV EACH OCCURRENCE ~ 1 000 QQ( A X X COMMBRGAL GENERAL LIABILITY L7205699 3.10.2007 3-10-2008 PReMlgs FW rvr,n S 50,00{ CLAIMS MADE ~X OCCUR ,e~.~ MFI"1FXP rln„nnn~ G Mr AGGREGATE LIIN17APPLlES PER: )MOBILE LIABILITY ANT AUTO ALL OWNED au7os SCHEDULED AUTOS HIRED AUTOS NON~O WNED Au70 GARAGE LUIBILITY ANV ALITQ ExceggrUMBRELLA LIABA.ITY OCCUR a CLAIM9MADE OEDUCI'Ies,E RETENTION $ WORKERS COMPEN$AnaN A/~ EMPLOYERS' ligBILITV ANV PROPRfETOR/PARTNER/EXECU7IVE OFFIGER/MEMBER EXCLVOED7 If yye4 deectiho undor SPE~IALPROWRIQN$bufow _ aTFIER ~~ PERSONALaADVINJURY s EXCLUDED GENERAL AGGREGATE ~ ~ aoo oao PRODUCTS~COMP/OPAGG s FYCI llllgl"f 1 Ca~ngINED SINGLE LIM1T $ (Ea eccldanl) BODILY INJURY 3 (Pet psrcon) BODILY FNJORY (Per nccitlenq 3 PROPERTY DAMAGE ~ (Per aeelden[) AUTO ONLY/EaAGCIDENT S OTHER THAN EA ACC g AUTO ONLY: AGG S EACH OCCURRENCE $ $ IEBCRIPTI ON OF OPERAT10N91 Lo CATIONS I V EHICLEtg I EXCL USION6 ADDED BY ENOORSEMEM' r SPECIAL PROWSI ONS POLITICAL CAMPAIGN HEADQUAF2'T'ERS FFECTIVE SEPTEMBER 8, 2007 THE CERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED HOLDER ALSQ LISTED AS ADDITIONAL INSURED: UNIVER517Y SETTLEMENT 724 WOICOTT AVENUE BEACON, NY 12508 :ANCELLATION SHOULD ANV OF TNG ABOVE DESCR16ED POLICIES BE CANCELLED 9EFORE THE EXPIRATION DATE THEREOF, TK£ IB&UING WBURER wlLl ENDEAVOR TO MAIL 15 DAYB WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO TNL LEFT, BI,1T FAILURE TO DO SO SHALL IMP08E NO OBLIGATItlN aR LIABILITY OF ANY KINb UPON THE INSURER, ITS AOENTa OR 'ACOROCORPO r ~~~~~M CERTIFICATE OF LIABILITY INSURANCE o8iiiiz o ' PRODUCER (914) 738-0100 FAX (914) 738-4568 Mil Brandt & Co. , Inc. 159 Main Street THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 2nd Floor New Rochelle, NY 10801 INSURERS AFFORDING COVERAGE NAIC # INSURED Asbestos Corporation of America INSURER A: American Int'1 Specialty Lines 791 Nepperhan Avenue INSURER B: Commerce & Industry Ins. Co. Yonkers, NY 10703-2012 INSURER C: INSURER D: INSURER E: CnVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' rypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY PROP 1419985 04/06/2007 04/06/2008 EACH OCCURRENCE $ 1 ~ 000 ~ 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50 ~ 000 CLAIMS MADE a OCCUR MED EXP (Any one person) $ 5 ~ 000 A X Asbestos & Lead PERSONAL & ADV INJURY $ 1 ~ 000 ~ 000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 1 ~ 000 ~ 000 POLICY PRO- LOC JECT AUT OMOBILE LIABILITY CA 934-35-08 04/06/2007 04/06/2008 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,00 ALL OWNED AUTOS BODILY INJURY B SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY PROD 1420283 04/06/2007 04/06/2008 EACH OCCURRENCE $ 9, 000, OQ X OCCUR ~ CLAIMS MADE AGGREGATE $ 9 , 000, 00 A $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC 531-39-67 08/24/2007 08/24/2008 X WC sTATU- oTH- B EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1, OOO, OO OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 1, UUU, OO If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ 1 , 000 , 000 OTHER DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT / SPECUIL PROVISIONS For any and all projects performed at the Carnworth Farms, Greystone Road, Wappingers Falls, NY, for the coverage period. Certificate Holder, Carnworth Farms, QuES&T. Inc. and William Manfredi Construction Corp. are included as Additional Insureds, as their interest may appear, as required by written contract, with respect to General Liability. Town of Wappinger Falls Attn: Mr. Joseph Ruggiero, Town Supervisor 20 Middlebush Road Wappingers Falls, NY 12590 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILUR~O MAIL SUCH NOTICE SHALL IMPOSE NO O/'B~LIGATION OR LIABILITY OF ANY KIND PON THE INSURER, ITS AGENTS OR REP ^ENTATIVES. _ ACORD 25 (2001/08) ` ) "' ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08)