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2009 (9).DESCRIPTIONS ;(Continued from .Page 1) Unterreiner, 10 Ellens Way, Wallkill, NY 12589, Stephanie Unterreiner, 196 Stout Court, Poughkeepsie, NY 12601, County of Dutchess, 22 Market Street, Poughkeepsie, NY 12601. AMS 25.3 (2001/08) 3 of 3 #S229827/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 (Only required if coverage is specifically ld. Federal Employer Identification Number of [nsured 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 DTJU6964K788 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 Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment ofpremizrms 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 Certiftcate 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: 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-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. C-105.2 (9-07) Reverse ~ ' 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 of Insured (Only required if coverage is specifically ld. Federal Employer Identification Number of Insured 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 20 Middlebush Road 3b. Policy Number of entity listed in box "la" Wappingers Falls, NY 12590 DTJUB964K788 3c. Policy effective period 04/02/09 to 04/02/10 3d. The Proprietor, Partners or Executive Officers are © 1nCluded. (Only check box if atl 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 (Nl~ 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 Insz~rance Carrier will also notify the above certificate holder within 10 days IFa policy is canceled dz~e to nonpayment of premiz~ms or within 30 days IF there are reasons other than nonpayment of premizrms that cancel the policy or eliminate the inszrred from the coverage indicated on this Certificate. (These notices may be sent by regzzlar 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 cet•tify that I am an authorized representative or licensed agent of ttoe 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 noY 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 ACOS~M CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 04/03/2009 PROaUCER (914)471-6200 FAX (845)471-9174 Hickey Finn & Co. Inc. 19 Davis Ave THIS CERTIFICATE tS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Poughkeepsie, NY 12603 Amanda Semenchuk INSURERS AFFORDING COVERAGE NAIC # INSURED Hudson Valley Heating Co. , Inc . INSURER A. Oh70 Casualty ] J C Electric, Licensed Contractor INSURER e: Majestic Insurance company 4 South Clinton Street INSURER C: Poughkeepsie, NY 12601 INSURER D: INSURER E: C VE 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYpE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 ~ OOQ ~ 00 X COMMERCIAL GENERAL LIABILITY BLO (09) 53 2 5 77 96 10/07/2008 10/07/2009 DAMAGE TO RENTED $ 50 ~ 00 CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ 5 ~ 00 A PERSONAL & ADV INJURY $ 1 ~ Q00 000 GENERAL AGGREGATE ~ $ 2 OQO 00 GEN'L AGGREGATE LIMIT APPLIES PER: PRO PRODUCTS - COMPIOP AGG ~ ~ $ 2 ~ 000 ~ 00 - POLICY JECT LOC AU TOMOBILE LIABILITY BAO (U9) 53257796 02/25/2009 02/25/2010 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1 000 00 ALL OWNED AUTOS BODILY INJURY , , A SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-0WNEDAUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO EA ACC OTHER THAN $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ ]- ~ QDQ ~ 000 X OCCUR ~ CLAIMS MADE USO (O9) 53257796 10/08/2008 10/08/2009 AGGREGATE $ 1 ~ Opp ~ OOp A $ DEDUCTIBLE $ X RETENTION $ 10,00 $ WORKERS COMPENSATION AND ' X WC STATU- OTH- B EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1 000 > > 000 OFFICERlMEMBER EXCLUDED? If d E.L. DISEASE - EA EMPLOYE $ 1, OOO, OO yes, escribe under SPECIAL PROVISIONS below 02 0080 5 018-02 U4/U1/2009 0401/2010 E.L. DISEASE -POLICY LIMIT $ 1, Q00, 00 OTHER ~ECEI~~, DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES !EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS p p~ ~ e ~~~~ ertificate holder is listed as additional insured /~ {~ 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, Town of Wappi nger BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 20 Mi ddl ebush Road OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESEN ATNES. Wappingers Falls , NY 12 590 AUTHORIZED REPRESENTATNE Daniel Hickev ACORD 25 (2001108) FAX: (845)297-0579 ©AC~ CORP~RATyLT'N 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) 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)452-5400 Hudson Valley Heating Co., Inc. 6 South Clinton Street lc. NYS Unemployment Insurance Employer Registration Poughkeepsie, NY 12G01 Number of Insured 52-11341 Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, i.e. a ld. Federal Employer Identification Number of Insured or Wrap-Up Policy) Social Security Number 14-1466015 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Majestic Insurance Company 3b. Policy Number of entity listed in box "la": Town of Wappinger 20 Middlebush Road 0200805018-02 Wappingers Falls, NY 12590 3c. Policy effective period: 04/01/2009 to 04/01/2010 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 "la" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment 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: Daniel G. Hickev, Sr. (Print name of authorized representative o,L.lj~erkce~! went ofinsurance carrier) ~ ~ Approved by: (Signature) ~ 3 U~ (Date) Title: 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)