Loading...
2009 (3)1 Y~ - r ~~y~ New York State Insurance Fund Workers' Compensation & Disabilit~> Benefits Specialists Since 1914 1 WATERVLIET AVENUE ALBANY, NEW YORK 12206-1649 Phone: (518)437-6400 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~~~~~~ RIVER REMODELING INC 90 FIDDLERS BRIDGE RD STATTSBURG NY 12580 POLICYHOLDER RIVER REMODELING INC j 90 FIDDLERS BRIDGE RD STATTSBURG NY 12580 POLICY NUMBER A 1230 087-7 I CERTIFICATE HOLDER TOWN OF WAPPINGERS 20 MIDDLEBUSH RD WAPPINGER FALLS NY 12590 CERTIFICATE NUMBER ~ PERIOD COVERED BY THIS CERTIFICATE 852157 I 04/01/2009 TO 04/01/2010 DATE - _- 11 /2/2009 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1230 087-7 UNTIL 04/01/2010, 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, 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 04/01/2010 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 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 ~ ~ 2~~~ ~~~SN~R ~L~~~ NEW YORK STATE INSURANCE FUND ~~ ~~ 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: 1073336947 U-26.3 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) Dutchess Bldg Specialists Inc &Dutchess Decking 488 Freedom Plains Rd St130 Poughkeepsie, NY 12603 Work Location of Insured (Only required if coverage is specifically limited to certain locations in New XorkState, i.e a Wrap-Up Policy) lb. Business Telephone Number of Insured 845-485-8343 1 c. NYS Unemployment Insurance Employer Registration Number of Insured 3921418 1 d. Federal Employer Identification Nu f Insured or Social Security Number ' 141735231 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) TOWN OF WAPPINGERS BUILDING DEPT 20 MIDDLEBUSH ROAD WAPPINGER FALLS, NY 12590 3a. Name of Insurance Carrier ~~ ~' WESCO 3b. Policy Number of entity listed in box "la ~~~/,~~ WWC3002852 A '~' 3c. Policy effective period: 12!01109 to 12/01/10 3d. The Proprietor, Partners or Executive Officers are: ^ included. (Only check box if all partners/officers included) ®all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box " 3" insures the business referenced above in box "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 note the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment ofpremiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices maybe sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed ageng or until the policy expiration date listed in boz "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: John P. O'Shea (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ~ , l ' ~~~+~+•s~+, 12/8/09 (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 845-454-0800 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) www.wcb.state.ny.us 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) Reverse 'i"^'~ ~ H(..,.vKLJ CERTIFICATE OF LIABILITY INSURANCE DATE(MM~UD/YYYY) `"''~ 08/31 /2010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE H OLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED subject to , the terms and conditions of the policy, cert4in policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Stuart E. Cohen Ltd & Somers Agency 293 Route 100 Suite 109 P"°NE 914-276-3222 FP'X 914-276-3227 ac No Somers, NY 10589 E-MAIL ADDRESS: insure stucohen.us PRODUCER 646 INSURERS AFFORDING COVERAGE NAIC k INSURED INSURERA:MerChdntS MUtU1~ Ins ~O 23329 ENERGY ELECTRIC STEPHAN KROELL dba INSURER B: Fi rst Rehabi 1 i tati on 81434 22 BROOKDALE ROAD INSURER C MAHOPAC, NY 10541 INSURER D INSURER E INSURER F I.rVVtKAl5t3 GtK11hIGATE NLIM6ER~ DCVlclnal ~ulaaoee. THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE A B POLICY NUMBER MM/DDrYYri MM D YDrYEYYI' LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY A R o PREMISES Ea occurrence 500,000 $ / ~ A CLAIMS-MADE OCCUR MED EXP (Any one person) 15,000 $ ~ BOP9092601 03/08/10 03/08/11 / Contractual liability-included PERSONAL 8 ADV INJURY $ INCL GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 2,000,000 / POLICY PRO LOC $ AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 000 0 ANY AUTO (Ea accident) , , 00 ALL OWNED AUTOS BODILY INJURY (Per person) $ A SCHEDULED AUTOS CAPI041872 BODILY INJURY (Per accident) $ 03/08/10 03/08/11 pROPERTYDAMAGE $ HIRED AUTOS (Per accident) / NON-OWNED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ~ N / A E.L. EACH ACCIDENT $ (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ B NYS DISABILITY D272164 03/19/10 03/19/11 STATUTORY DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Renarks Schedule, If more apace is required) JOB: NATHANS PROJECT ADD'L INS'D: TOWN OF WAPPINGERS,20 MIDDLE BUSH ROAD, WAPPINGERS FALLS, NY 12590 M. ANTHONY ENTERPRISES, INC PO BOX 859 BREWSTER, NY 10509 LLIY I IVIY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATNE ACORD 25 (2009/09) ~'19tis-zoo9 ACORD CORPORATION. Ail rights reserved. The ACORD name and logo are registered marks of ACORD ~CORD® CERTIFICATE OF LIABILITY INSURANCE ioi21~2 og 'RODUCER (845) 471-6200 FAX: (845) 471-9174 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Hickey-Finn & Company ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 15 Davis Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Poughkeepsie NY 12603 NSURED Fairview Hearthside Distributors LLC 66 Violet Avenue NY 12603 ^(lVFRO(~FS INSURERS AFFORDING COVERAGE INSURERA Sel@Ct1Ve Ins CO of America wsuRER B Merchants Mutual .Ins Co INSURER C: INSURER D: INSURER E: __ NAIC # _ 26301 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 oni iricc nr_r_aFanrF I IMITR cNnvuN MAY HAVE BEEN REDUCED BY PAID CLAIMS. JSR ADD'L ~ POLICY NUMBER POLICY EFFECTNE POLICY E P LIMITS AT D ATE MIDD .TR ' 000,000 ' EACH OCCURRENCE ~ $ 1, 'GENERAL LIABILITY MMERCIAL GENERAL LIABILITY IX co _ -r -- DAMAGETO RENTED ~ PREMISES (Ea occurrence _~ $ _ 100.,-000 l I A X I ;CLAIMS MADE ~ X j OCCUR 51879165 10/14/2009 '' 10/14/2010 I MED EXP (Any one person) I $ 51 000 ' - - - --- - i PERSONAL 8 ADV INJURY $ 1~ 000 X000 - -- - -- ---- ( GENERAL AGGREGATE $ _2_, 000 r 000 GEN'L AGGREGATE LIMIT APPLIES PER: ' i PRODUCTS - COMPIOP AGG $ 2 L000 , 000 i --- - --~-.-.._ I j 'PRO- I X ,POLICY T LOC ~ AUTOMO&LE LIABILITY ~ COMBINED SINGLE LIMIT $ 1 , 000 , 000 ~- - , ~ I AN ~~ (Ea accident) ~ -- ---- - r-- A ~ X ALL OWNED AUTOS 51879165 i I 10/14/2009 i i 10/14/2010 gODILYINJURY ~ $ ' ~--~ (Per person) . ~i SCHEDULED AUTOS i j ( , - _ __ _-- -~-- r--~ I X ~ HIRED AUTOS i BODILY INJURY I, $ ident) P ~X ,NON-OWNED AUTOS er acc j ( -- ----""---------- f - ----- ~ I ' ( PROPERTY DAMAGE $ i--- - -- - -- - ~ (Per accident) ~ ACC ;AUTO ONLY - EA $ RAGE LIABILITY _ I - ---- , ~ ! -, ANY AUTO ' I EA ACC - --~- ------ ---- i OTHER THAN - AUTO ONLY: AGG $ ig ~ I I EACH OCCURRENCE I $ __ 3~ 000, 000 - ---- ---- - ----- , EXCESS/UMBRELLALIABILITY (--i CLAIMS MADE X j ~ I 'AGGREGATE __ ~_ 3 , 000 ~OOO ----- -- OCCUR l-~ - ~ ~ _ __ -- I i ~- DEDUCTIBLE B I i UP9140105 0 ~ 10/20/2009 _ _ 10/14/2010 'r _-. _-___ _ __._~ $ _~ I ~ $ i 10,00 RETENTION $ X WC STATU- ~ OTH- S COMPENSATION WORKER I j i ,___ ' TQRY~,.IMITS__.__..~_L=R 'i __ _-_ _---.-_---- j AND EMPLOYERS' LIABILITY y / N VE ' ~ E.L. EACH ACCIDENT $ I'----_ _ -------- -- ------------ ^ ANY PROPRIETORIPARTNER/EXECUTI OFFICER/MEMBER EXCLUDED? ' I ~ j E.L. DISEASE - EA EMPLOYEE $ _____ ,__ -_._------...-- ----- f--- - (Mandatory in NH) ~ If yes, describe under E.L. DISEASE -POLICY LIMIT I $ 'SPECIAL PROVISIONS below OTHER ~ i I Q-~ I DESCRIPTION OFOPERATIONS /LOC ATIONS I VEHICLES / EXCLUSIONS Auutu tsr enwRxmciv i ,or~..~ ..~ • ••.....•..,.... (~(~ TOWN OF WAPPINGER IS NAMED AS ADDITIONAL INSURED .~*--.,~ ~,.,,,,,~~ 411,'T ? ~~ 2DI~9 ~ !~ K TE Town of Wappinger Building Department 20 Middlebush Road Wappingers Falls, NY ACORD 25 (2009101) INS025 (2oosot ) SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED$EFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 12590 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Daniel Hickey/VP ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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). ff 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 This certificate of Insurance 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. .CORD 25 (2009101) JS025 ~zoosoi>