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2009 (7)Cliant#• ~RQRS _.._.. _... ___~.. AUCLIrV IYJ ACORDTM CERTIFICATE OF LIABILITY INSURANCE Dom) 04/01/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Treiber Group,A/D/O Arthur ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE J Gallagher Co of NY Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 377 O k St t CS 601 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. a ree - Garden City, NY 11530-0601 INSURERS AFFORDING COVERAGE NAIC # INSURED Adelhardt C t ti C i INSURER A: The Travelers Indemnity Co. of CT 25682 ons ruc on orporat on N 241 West 30th St t INSURER B: ational Casualty Company 11991 ree 4th Fl INSURER c: Travelers Property Casualty Co. of A 25674 oor New York NY 10001 INSURER D: Travelers Surety & Casualty 36161 , INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REDUIREMENT, 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 LTR DD' N R TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS A GENERAL LIABILITY DTNYC0964K7884 04/02/09 O4IU2MO EACH OCCURRENCE $1 UUU.UUU X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $300 UUU CLAIMS MADE a OCCUR MED EXP (Any one person) $1 U UUU PERSONAL & ADV INJURY $1 000 UUU GENERAL AGGREGATE $2 000 UUU GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $2 OOO OOO POLICY X PRO LOC JECT A AU TOMOBILE LIABILITY DT810964K7884 04/02/09 04/02/10 X ANY AUTO COMBINED SINGLE LIMIT (Eaaccident) $1,000,UUU ALL OWNED AUTOS BODI Y SCHEDULED AUTOS L INJURY (Per person) $ X HIRED AUTOS BOD Y X NON-OWNED AUTOS IL INJURY (Per accident) $ P ROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO EA ACC OTHER THAN $ AUTO ONLY: AGG $ B EXCESSIUMBRELLA LIABILITY UM00031743 04/02/09 O4IO2I1O EACH OCCURRENCE $5 OOO 000 X OCCUR ~ CLAIMS MADE AGGREGATE $5 UUU OOO DEDUCTIBLE $ X REr~:r:TION $ 10,004 - ---____._. $ C WORKERS COMPENSATION AND . DTJUB964K7884 _ 04102109 ~ G4/U2/10 X bb C. STATU- OTH- C EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE E.L. EACH ACCIDENT $5OO UUU OFFICERIMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $SOO,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $5UU UUU D OTHER Crime 104897482 03113/09 03113/10 $1,000,000 3RD Party Covg. Emp. Theft DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES !EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ACC Job #1526 JP Morgan Chase 1460 Route 9 Wappingers Falls NY ~~('~E~, /~~' V' V ~ The following are included as Additional Insureds, where required by ~ written contract with respects to General Liability: at Eric Unterreiner, 10 Ellens Way, Wallkill, NY 12589 and Stephanie ~~ ~ ~ ~tr~~y Unterreiner, 19B Stout Court, Poughkeepsie, NY 12601. -~., CERTIFICATE HOLDER CANCELLATION "-="p'-'flet ~a.~~'~ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Wappingers Falls DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _30_, DAYS WRITTEN 20 Middlebush Road NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Wappingers Falls, NY 12590 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORI2E0 REPRESENTATIVE . I`- ACORD 25 (2001/08) 1 of 2 #S229828/M229821 a LGU ©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 25-5 (2001/OB) 2 of 2 #S229828/M229821 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 Adelhardt Construction Corporation 212.279.3700 241 West 30th Street 4th Floor lc. NYS Unemployment Insurance Employer New York, NY 10001 Registration Number of Insured 1584059 Work Location oflnsured(Onlyrequiredifcoverageisspecifically 1d. FederalEmployerldentificationNumberofInsured limited to certain locations in New York State, i.e., a Wrap-Up or Social Security Number Policy) 111987591 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate' Holder) Travelers Property Casualty Company of America Town of Wappingers Falls 3b. Policy Number of entity listed in box "la" 20 Middlebush Road Wappingers Falls, NY 12590 DTJUB964K788 3c. Policy effective period 04/02/09 to 04/02/10 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 Instu~ance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled dt~e to nonpayment ofpremiz~ms or within 30 days IF there are reasons other than nonpayment of premia~ms that cancel the policy or eliminate the insured from the coverage indicated on this Certifccate. (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' compensatiou 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: H. Craig Treiber (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ~'~ 04/01/09 (Signature) (Date) Title: CEO Telephone Number of authorized representative or licensed agent of insurance carrier: 516-745-0800 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. 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. C-105.2 (9-07) Reverse 1 ` 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) 1 b. Business Telephone Number of Insured Adelhardt Construction Corporation 212.279.3700 241 West 30th Street lc. NYS Unemployment Insurance Employer Registration 4th Floor Number of Insured New York, NY 10001 1584059 1 d. Federal Employer Identification Number of Insured or Social Security Number 111987591 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) National Benefit Life 3b. Policy Number of entity listed in box "la": Town of Wappingers Falls 0891015840590 20 Middlebush Road Wappingers Falls, NY 12590 3c. Policy effective period: 02/06/09 to 02/06/10 4. Policy covers: a. O 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 licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability Benefits insurance coverage as described above. Date Signed 04/01/09 B '~-~~df.(,~~~Gj~ Y (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516.745.0800 Title President IMPORTANT: If box "4a" is checked, and this form is signed by the insurance carrier's authorized. representative or NYS Licensed Insurance Agent of'that carrier, this certificate is COMPLETE. Mail it directly to the certificate holder. If box "46" is checked, this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed for completion to the Workers' Compensation Board, DB Plans Acceptance Unit, 20 Park Street, Albany, New York 12207. PART 2. To be completed by NYS Workers' Compensation Board (Only if box "4b" of Part 1 has been checked) State Of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation Board, the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date Signed By (Signature of NYS Workers' Compensation Board Employee) Telephone Number Title Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (5-06) •~ Additional Instructions for Form DB-120.1 By signing this form, the insurance carrier identified in box "3" on this form is certifying that it is insuring the business referenced 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 t/ie policy expiration slate 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 la~x~ 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 OP ID DB AC©RD CERTIFICATE OF LIABILITY INSURANCE ANCHO-2 DATE (MM/DD/YYYY) 04 0l 09 PRbDUCER Main Street America Group - Sy Syracuse Region PO Box 2027 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. Keene NH 03431 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: NGM Insurance Company 14788 INSURER B: Anchor Electric InC INSURER C: 38 FOX Road INSURER D: Hopewell Junction NY 12533 INSURER E: Cl1VPR Ar FS 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 MAYBE 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER P Y EFFE TIVE DATE MM/DD/YY P LI Y XPIRATI DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2 r OOO , OOO A X COMMERCIAL GENERAL LIABILITY MPV53655 08/10/08 08/10/09 PREMISES (Eaoccurence) $500r000 CLAIMS MADE ®OCCUR MED EXP (Any one person) $ 10 r 000 PERSONAL & ADV INJURY $ 2 r OOO ~ OOO GENERAL AGGREGATE $ 4 r OOO r OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 4 r OOO ~ OOO POLICY $ PRO (~ LOC JECT AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ 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 EACH OCCURRENCE $ OCCUR ~ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ - $ WORKERS COMPENSATION AND _ TORY LIMITS ER A EMPLOYERS'LIABILITV WCV53655 08/10/08 08/10/09 E.L. EACH ACCIDENT $ 100 r 000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 100 ~ 000 If yes, describe under E.L. DISEASE -POLICY LIMIT $ 500 r 000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS !VEHICLES !EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS All duties usual and customary to Electrical Work within Buildings AD PR ~i ®~ Ceti, C102 .5 IS ATTACHED "~ ,:~ ~ _. _ _ _ ..._ "'"~I --- - ~ ~-~~~ ~' -- ~E~RK ('ANr'FI 1 0111 IN V Gl~llrl Vf'11L t -- - - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL TOwn of Wappinger IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 20 Middlebush Rd. NY 12590 ll F REPRESENTATIVES. s a Wappinger TIVE A~ORIZE~D `R` RES ACORD 25 (2001/08) 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 (2001108) 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) 1b. Business Telephone Number of Insured ANCHOR ELECTRIC INC 38 FOX RD HOPEWELL JCT, NY 12533 1 c. 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) 1 d. 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) NGM/MSA 3b. Policy Number of entity listed in box "la": TOWN OF WAPPINGER WCV53655 20 MIDDLEBUSH ROAD 3c. Policy effective period: WAPPINGER FALLS, NY 12590 8/10/OS to 8/10/09 3d. The Proprietor, Partners or Executive Officers are: ^ 1nClUded. (Only check box if all partners/officers included) X 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 "1a" 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 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: -DAWN BUCKLEY (Print name of authorized representative or licensed agent of insurance can~ier) Approved by: Title: SR/CSR (Signature) Licensed Agent_DAWN BUCKLEY Telephone Number of authorized representative or licensed agent of insurance carrier: _800-25-5646 -~ - l~ (Date) Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2 (12-03) Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any 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 byfiling 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 ~IJ~TFnR_n~ rnnfn AcoRp CERTIFICATE OF LIABILITY INSURANCE DATE(IdMIDG!1^iYY) ~, -- 3!23!2009 PRODUCER (716) 759-9606 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION W. J. COX ASSOCIATES, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 9600 MAIN ST SUITE 3 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ., ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Clarence, NY 14031-2093 INSURERS AFFORDING COVERAGE NAIC # INSURED Custom Forest Products Inc ;;~J~~UREE,4 North American Specialty Ins Co 57 W Meadowbrook Ln ;NSUREF e -- Staatsburg, NY 12580 ------ - - - ~rJSURER If1SUF'.ER G MSURER E COVERAGES THE POLICIES OF INSURANCE LISTED 6ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IPJDICATED. NOTVUITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF AMY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MA`( 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 EY PAID CLAIMS. IfJSR DD'L - ~ _ ~ POLICY EFFECTIVE i POLICY EXPIRATIOf•1- - ~ _ - _ ~ -- LTR NSRD TYPE OF If,ISURAN E POLICI' fJUMBER DAT MM1D M' DATE MM/DDM' LIMITS GENERAL LIABILITY EACH OCCUFRE~.IrE $ 1,000,000 A ~ X ~~~4,1;•,II ~ _;y~_ ~:ErI~R .~ L~ oiurr AJC 0000027 07 2/20/2008 ~ 2/20/2009 FR nnist I'LL ~,__~a~ i~o,~ r 100,00 c~ ;I~~ rn.~,oE ~ _>_~~~F: ~ fnED ExP r r~ ~ma L r,~,r1 f~ 5,00 ~ PERSOrJ~L?.a~,v;rl_~~~R~~- ~ - --1,000,00 r_,erJER^LAGi~f3E~~P.T_ F 2,000,000 I .Fill '~~~~PE-4TE~_IMIT~,PPLIE`_~~'EF' ___ PRJGUt.T _!'I~IGL ~ _ _. _ _ 2,OOD,DO P _._.__- __-__ PnLKY ,;EcT ~ AUT OMOBILE LIABILITI' I CONIEtINLD SII'd~;LE U"•,IIT {' ",Pfi ,W ITi ~ ~ iEd accitlenf) '.L_ ~ .'.. dJED -L;TO` ~ EJCNLY I-;JURi ' i ~~-HELn iLE`_ '!h:, , 'i rFai ~~ers~ni) , f _ , _ ~~ AEG ;; E CILt do F'i I I P~FG fl Cl1U ~C'= ~~ fF rvxa .nl~ ' FF ERTr C'1vt~6F ~~/ ~ ~ i va'i i of f {/ •! GAR AGE LIABILITI' ~i ",1 iT~~ nhlLr' - E.~. ??~ r I~ f , ', - THER THAfJ ' '~. UTO OPILI': EXCESSIUMBRELLA LIABILITY E4CH OC i IMF EhdrE { A rJ.=UR ~ L.', Ibt~ h1NDE ----- - --_ A3C~RE~.?TE - _ f ' _ ___ f -___ DEDUCTIBLE _ $ RETENTION ~ $ _ '~~C ST>~iii i- ~~~H- WORKERS COMPENSATION AND TORY LIMIT; _ EF EMPLOYERS' LIABILITY RN`(FROPRiETORlPARiT~lER1EY ECUTIVE EL EACH NCCIDENT _ {; . OFFICERlA.9EMBE~7 ExCLUDED" ~ EL pISEASE - EA EMPL~7; EE T If yes, describe under -~~~- SPEChL PROVISIONS below E.L. DISEP,SE - FULICY LI!vilT $ OTHER DESCRIPTION OF OPERATIONS !LOCATIONS !VEHICLES !EXCLUSIONS ADDED BY EPJDORSEMENT! SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Wappingers DATE THEREOF THE ISSUING INSUR R WI 1 O 20 Middlebush Rd , LL ENDEAVOR TO MAIL E DAPS WRITTEN Wa Jn ers Falls, NY 12590- pp 9 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILrrY OF ANY KIND UPON THE INSURER, RS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE - ACORD 25 (2001/08} O ACORD CORPORATION 1988 ACORD 25 (2001/08) ACORD CERTIFICATE OF LIABILITY INSURANCE OPID NC DATE (MM/DDM'YY) AMER-47 03 23/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Rose & Kiernan, Inc (Pawling) HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 527 Route 22 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Pawling NY 12564 Phone: 845-350-3800 Fax: 845-350-3901 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: American international Special INSURER B: Peerless Insurance Company 273 American Petroleum Equipment & Construction Company Inc. INSURER C: eirst rehabilitation insurance 63 Orange 12586e Walden INSURER D: __ INSURER E: COVERAGES /Y~~ THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDI /1' ~ ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED 0 V MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ~~''~~//~~ LTR NSR TYPE OF INSURANCE POLICY NUMBER P LI Y EFFE DATE MM/DD P LI Y I N DATE MM/DD/YY ~ LIMIT GENERALLU\BILITY EACHOCCURR ! $ 1000000 A X COMMERCIAL GENERAL LIABILITY PROP1759440 03/24/09 03/24/10 PREMISES (Eaoccurence) 0000 CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ 10000 PERSONAL&ADVINJURY $ 1000000 X Pollution & Prof GENERAL AGGREGATE $ 2000000 GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $2000000 POLICY PRO- LOC JECT AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ 100QQQQ $ X ANY AUTO BA8404523 03/24/09 03/24/10 (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GAR AGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO EA ACC OTHER THAN $ AUTO ONLY: AGG $ EXCESS/UMBRELLALIABILITY EACH OCCURRENCE $ 4000000 A X occuR ~ CLAIMSMADE PROU1759463 03/24/09 03/24/10 AGGREGATE $ 4000000 $ DEDUCTIBLE $ X RETENTION $N/A $ WORKERS COMPENSATION AND EMPL Y ' TORY LIMITS ER O ERS LU\BILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? If es de ib d E.L. DISEASE - EA EMPLOYEE $ y , scr e un er SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER C Disability D267344 01/01/07 Statutory DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT / SPECU\L PROVISIONS Operations usual to the business of insured. CERTIFICATE HOLDER CANCELLATION TOWNW04 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Town of Wappinger 20 Middlebush Road IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Wappinger Falls NY 12590 REPRESENTATNES. AUTHO ED REPR SENTATN ~. AGUKU Z5 (ZUU7/08) ~~ ' ~ ©ACORD CORPORATION 1988 ACORD CERTIFICATE OF LIABILITY INSURANCE OPID JFR$ DATE(MMIDDIYYYY) JDPAR-1 03 23 09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Marshall & Sterling, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 110 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Poughkeepsie NY 12601 Phone:845-454-0800 Fax:845-485-7804 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Herleyavllle lne. Co. oL ar 2 3 9 INSURER B: JD Parrella Electric IIIC INSURER C: 299 Washington St. Newburgh NY 12550 INSURER D: INSURER E: COVERAGES 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE MMIDDfYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ l O O O O O O A X COMMERCIAL GENERAL LIABILITY MPA8G8526 03/28/09 03/28/10 PREMISES Eaoccurence $ 100000 CLAIMS MADE a OCCUR MED EXP (Any one person) $ 5 0 0 0 PERSONAL 8 ADV INJURY $ 10 0 0 0 0 0 GENERAL AGGREGATE $ 2 0 0 0 0 0 0 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMP/OP AGG $ 2 O O O O O O POLICY $ JECT LOC $m B@n. 1000000 AUT OMOBILE LIABILITY A X ANY AUTO BA8C~8526 03/28/09 03/28/10 COMBINED SINGLE LIMIT (Ea accident) $ l 0 0 0 0 0 0 ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ X HIRED AUTOS ]( NON-0WNED AUTOS BODILY INJURY (Per accident) $ PR OPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ l O O O O O O B X OCCUR ~ CLAIMSMADE BE8G8526 03/28/09 03/28/10 AGGREGATE $ 1000000 DEDUCTIBLE $ X RETENTION $ 1 0 0 0 O $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE CERTIFICATE ISSUED 01/01/09 11/01/09 E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? If yes, describe under SEPARATELY E.L. DISEASE - EA EMPLOYEE $ SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS MAR ~ ~ 2QU'~ ~, ~'O,WIV C-.~RK ~.Crtllf Il.A1C YIVLUtK CeuCFI I eTln-J Town of Wappiager Attn: Shelly 20 Middlebush Road Wappingers Falls NY 12590 ACORD 25 (2001108) WAPP 0 0 5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 O 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 REPRESENTATIVES. © ACORD CORPDRATI~N 19RR