Loading...
2009 (10)Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. i. 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 `AGORD CERTIFICATE OF LIABILITY INSURANCE OP ID DGRA DATE (MM/DDA'YYY) BRIDG-6 04 01 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: TeChn010 Insurance CO INSURER B: Bridge V1eW Excavation Ina INSURER C: 3 Van Wyck Ln Su1te 1 INSURER D: Wappingers Falls NY 12590 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 POLICY EFFECTIVE DATE MM/DD/YY POLICY EXPIRATION DATE MM/DDIYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence) $ CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ POLICY PRO- JECT LOC 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 EA ACC OTHER THAN $ AUTO ONLY: qGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ~ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND A TORY LIMITS ER A EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE TWC3199841 04/01/09 04~O1~10 E.L. EACH ACCIDENT $ lOOOOO OFFICER/MEMBEREXCLUDED? E.L. DISEASE-EA EMPLOYEE $ lOOOOO If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE-POLICY LIMIT $SOOOOO OTHER Commercial Applica DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS APR 0 ~ 2009 CERTIFICATE HOLDER CANCELLATION Town of Wappingers 20 M.iddlebush Road Wappingers Falls NY 12590 TOWN03 6 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 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 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 (2001108) To: Certificate Holder 03/26/2009 Since our insured's Automobile policy renewed on 03/01/2009 attached is updated paperwork so that your file is current. You will receive another updated COI when our insured's General Liabili policy renews on 06/11/2009. ~ Any questions, feel free to contact me directly @ (631) 567-1011. Thank you, Kathleen CQl~Y ACORDM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) o31zs12oos PRODUCER Hometown Insurance Agency of L.I., Inc. 5 Orville Drive, Suite 400 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. Bohemia, NY 11716 631 567-1011 INSURERS AFFORDING COVERAGE NAIC # INSURED Fire Guard of Long Island, InC. INSURER A: Indian Harbor IfISUranCe Co. 40-8 Burt Drive INSURER B: Merchants Insurance Co. INSURER C: Deer Park, NY 11729 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. INSR DD' POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X X COMMERCIAL GENERAL LIABILITY ESG0023332.01 0611112008 0611112009 DAMAGE TO RENTED $ 50,000 CLAIMS MADE ~ OCCUR MED EXP An one erson $ EXCLUDED PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 1,000,000 X POLICY PRO LOC AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 B X ANY AUTO CAP1040837 03101/2009 0310112010 (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per 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 EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ~ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ W C STATU- OTH- WORKERS COMPENSATION AND EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE - OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS Certificate Holder is an Additional Insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Wappinger DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN 20 Middlebush Road 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 Wappinger Falls, NY 12590 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ~/~~'~`.- <5`V~ ~/~/J~ 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. ~-G,c7y ACORD 25 (2001/08) ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID TV DATE(MM/DD/YYYY) TIMEL-1 03 31 09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rose and Kiernan, Inc . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P 0 Box 64 0 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 9 Troy Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. East Greenbush NY 12061 Phone: 518-244-4245 Fax:518-244-4262 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Ut1C8 National Assurance 375 INSURER B: Ut1Ca Mutual Insurance Co 364 Timely Signs of Kingston Inc. 154 Clinton Avenue, LLC INSURER C: 154 Clinton Ave INSURER D: Kin ston NY 12401 g 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 SHOW N MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE M~DD~ E DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ l O O O O O O A X COMMERCIAL GENERAL LIABILITY CPP4027289 04/01/09 04/01/10 PREMISES (Eaoccurence) $ 100000 CLAIMS MADE a OCCUR MED EXP (Any one person) $ 1 O O O O PERSONAL & ADV INJURY _ $ l O O O O O O X GL Ext.Endt/Blkt GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 2 O O O O O O POLICY PRO- LOC JECT Em Ben. lOOOOOO AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT A X. ANY AUTO CPP4027289 04/01/09 04/01/10 (Ea accident) $ l O O O O O O 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: qGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 2 0 0 0 0 0 0 $ X OCCUR ~ CLAIMSMADE CULP4027290 04/01/09 04/01/10 AGGREGATE $ 2000000 DEDUCTIBLE $ X RETENTION $ l O O O O $ WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS' LIABILITY ANY PROPRIETOR/PARI"NER/EXECUTIVE E.L. F~CH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS (LOCATIONS (VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS All Operations Usual & Incidental to the Sign Installation, Erection &. Repair Business of the Named Insured `~~ ~, CERTIFICATE HOLDER CANCELLATION TOWNWO4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 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 TOwn of Wappinger 20 Middlebush Road IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Wappinger Falls NY 12590 REPRESENTATIVES. AUTHO ED REPR SENTATIV ACORD 25 (2001/08) ~ ~ ~ ©ACORD CORPORATION 1988 OP ID CR DATE (MMIDDIYYYY) AcoRQ. CERTIFICATE OF LIABILITY INSURANCE CREEK-3 03 31 09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Brinckerhoff & Neuville, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1134 Main St . , PO Box 424 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Fishkill NY 12524-0424 Phone.845-896-4700 Fax:845-897-5110 ~INSURERSAFFORDINGCOVERAGE 'NAIC# ------ ------------------ --- INSURED INSURER A. Mt . HdWley Insurance Co . I Creekview, Ltd. INSURER & Meadowood Investors LLC - -------- _ ~- - - - - Creekview Holdings wsuRER c P . O . Box 3 0 6 --- - - - _- --__ - --- --- ~ Hopewell Jct., NY 12533 INSURERD --- ---- ---- INSUREH E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWIT[ISTANDING 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. NSR WDD'U LTR INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDD/YY POLICY EXPIRATION DATE (MMIDD/YY) LIMITS GENERAL LIABILITY ~ EACH OCCURRENCE $ l, 0 0 0, O O O A I I- - ~ X COMMERCIAL GENERAL LIABILITY MCF0003485 04/01/09 0401/10 UANTAGET6REM1TFED------ --- PREMISESIEaoccurence) ~ ---_--- - $ 50, 000 l CLAIMS MADE ~~ OCCIIR -- -- _ MED EXP (Any one person) _~ -- _ __ $ __ --- ~ -_. _. _. __ ------- -__ __- .._. ~ PERSONAI 8 ADV INJURY $ 1, 0 0 0, 0 0 0 i GENERAL AGGREGATE $ 2, 0 0 0, 0 0 0 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS -COMP/OP AGG $ 1 , O O O , O O O j PRO- O C OC ~ ----.. __.._.-_-__-_ - - - ---_ _ ---- - - P LI L Y JECT AU _.. __. TOMOBILE LIABILITY COMBINED SINGLE LIMIT $ I ANY AUTO ( (Ea accidenq ALL OWNED AUTOS BODILY INJURY $ ~ (Per person) ~_ , SCHEDULED AUTOS I -_-- _ - -- - - ------ __. HIRED AUTOS - ~ BODILYINJURY ~ $ NON-OWNED AUTOS I (Per accident) - L II PROPERTYDAMAGE $ ~ I ~ (Per accident) j ~I GARAGE LIABILITY AUTO ONLY - EA ACCIDENT ~ $ ANY AUTO EA ACC OTHER THAN $ AUTO ONLY. AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE ; $ 1, 0 0 0, 0 0 0 A }', OCCUR ~ CLAIMSMADE MXL0413387 04/01/09 04/01/10 AGGREGATE. $ 1,.000,_000 - $ ~ DEDUCTIBLE _ $ ~ r ~ RETENTION $ _ ____ $ j WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS' LIABILITY E.I .EACH ACCIDENT $ ~ ANY PROPRIETOR/PARTNER/EXECUTIVE - --- -- ----- i OFFICER/MEMBER EXCLUDED? E.L. DISEASE. - EA EMPLOYEE $ ~~~ If yes, describe under ', SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ I OTHER i DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES I EXCLUSIONS AUUEU BY tNUURStMtN I r,PtC~AL rrcuvwwrva Operations in the State of New York ~' .~. CERTIFICATE HOLDER TOWNOFW Town of Wappinger 20 Middlebush Rd Wappingers Falls NY 12590 ACORD 25 (2001/08) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 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. TIVE RD CORPORATION 1988 ACORD,. RODUCER CERTIFICATE OF LIABILITY INSURANCE OP ID CR DATE (MM/DDIYYYY) CHRIS-3 03 20 09 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE srinckerhoff & Neuville, Inc . HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR .134 Main St . , PO Box 424 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 'ishkill NY 12524-0424 ?hone: 845-896-4700 Fax:845-897-5110 INSURERS AFFORDING COVERAGE ~ NAIC# JSURED I INSURERA: NatlOnal Grange..Mutual 14788 I....---- - ----- - _-._. _.....-..,. ..... -__..-_- INSURER B - ... - -... h ----- -- - -_.__. _. -. - _ . Chris-Bar Electric IriC. INSURER C: P.O. Box 506 INSURER D. Fishkill NY 12524 -_-- - --- _ _ _-_- , - INSURER E :OVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOT"WITHSTANDING 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. SRWDD'U TR INSRa TYPE OF INSURANCE ~ POLICY NUMBER ~ -POLICY EFFECTIVE DATE MMIDD/YY POLICY EXPIRATION DATE MM/DD/YY LIMITS I i GENERAL LIABILITY EACH OCCURRENCE $ 2, O D 0, D O O. ~. !---i A X I COMMFRCIALGENERALLIABILITY MPV5D472 05/12/09 05/12/10 MAGE-TO~RI=ATE6 -----._-j (Eaoccurence) ~ PREMISES _--- $ 500, DDD- (_ ~ -_-l J ~ ( ~ ~ CLAIMS MADE i .OCCUR I j . - - --.. -T MED EXP (Any one person) ~ - ~ ----- --- -~ __- --- $ 1 D , 0 D D -- ----- ' ~ I -- r ! PERSONA! 8 ADV INJURY. _ ~ $ 2 , O O O ,DDD , '. '~, GENERAL AGGREGATE ~' --- _.- - - $ 4 , O O O , O O O . - - - ------ j ~- - ---- ---- -- ', ~ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMPIOP AGG $ 4 , D O.O ,DDD . PRO- ~ POLICY LOC JECT AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) i ANY AUTO ____._.-._ _ ____ ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS _. _ -- --- HIRED AUTOS BODILY INJURY ' $ (Per accident) NON-OWNED AUTOS ~ _~ ____ PROPERTY DAMAGE ~ -' ~, I, (Per accident) i, it ~ GA RAGE LIABILITY AUTO ONLY - EA ACCIDENT $ i __ ANY AUTO OTHER THAN EA ACC $ - _ - t AUTO ONLY: AGG __ $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ jOCCUR ~ J CLAIMSMADE ~ AGGREGATE $ __ _ DEDUCTIBLE $ RETENTION $ $ I WORKERS COMPENSATION AND TORY LIMITS ER _ EMPLOYERS' LIABILITY E.L. EACH ACCIDENT _ $ -~~- ANY PROPRIETOR/PARTNER/EXECUTIVE I - _--- -~ '~ OFFICERIMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ I( es descnoe ender P I ~ DISEASE -POLICY LIMIT E L i $ ECIAL PROVISIONS below S . . i I OTHER DESCRIPTION OF OPERATIONS / LOGA710N5 / vtrocLts / tncwm~rva Huucu of CIVUVRJCIYICIY I r arc..w~ rR...w~.,~.~ operations in the State of New York ,`~' ~i .®' ;ERTIFICATE HOLDER TOWNOFW Town of Wappinger 20 Middlebush Rd Wappingers Falls NY 12590 aCORD 25 (2001108) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 D 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 CORPORATION 1988 POLICY NUMBER: MPV50472 BUSINESSOWNERS BP 04 52 01 97 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -STATE OR POLITICAL SUBDIVISIONS -PERMITS This endorsement modifies insurance provided under the following: BUSINESSOWNERS POLICY SCHEDULE* State Or Political Subdivision: Town of VVappinger 20 Middlebush Road Wappingers Falls NY 12590 " Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Decla- rations. The following is added to Paragraph C. Who Is An Insured in the Businessowners Liability Coverage Form: 4. Any state or political subdivision shown in the Schedule is also an insured, subject to the follow- ing provisions: a. This insurance applies only with respect to operations performed by you or on your behalf for which the state or political subdivision has issued a permit. b. This insurance does not apply to: (1) "Bodily injury", "property damage", "personal injury" or "advertising injury" arising out of operations performed for the state or mu- nicipality; or (2) "Bodily injury" or "property damage" in- cluded within the "products-completed op- erations hazard". cQ,ay BP 04 52 01 97 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 ^ C`IlnnHt• ~aoa~ A11C1 /~A\I~ ACORD.M CERTIFICATE OF LIABILITY INSURANCE DnvrY) 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 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 377 Oak Street - CS 601 Garden City, NY 11530-0601 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: The Travelers Indemnity Co. of CT 25682 Adelhardt Construction Corporation INSURER B: National Casualty Company 11991 241 West 30th Street INSURER c: Travelers Property Casualty Co. of A 25674 4th Floor INSURER o: Travelers Surety & Casualty 36161 New York, NY 10001 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. INSR LTR NS TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS A GENERAL LIABILITY DTNYC0964K7884 04/02/09 04/02!10 EACH OCCURRENCE _ $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED _ $3OO OOO CLAIMS MADE ~ OCCUR MED EXP (Any one person) $1 O OOO PERSONAL & ADV INJURY $1 OOO OOO GENERAL AGGREGATE $2 Q00 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $2 QQO 000 POLICY X PRO- JECT LOC A AUT OMOBILE LIABILITY DT810964K7884 04/02/09 04/02/10 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $110001000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per 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 EA ACC $ AUTO ONLY: AGG $ B EXCESS/UMBRELLA LIABILITY UM00031743 04/02/09 04/02/10 EACH OCCURRENCE $S OOO OOO X OCCUR ^ CLAIMS MADE AGGREGATE $5 OOO OOO DEDUCTIBLE $ X RETENTION $ 1O OOO $ C WORKERS COMPENSATION AND DTJUB964K7884 04/02/09 04/02/10 ~( WG STATU- Ol'H- `. EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $5OO OOO ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $5OO OOO If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $5OO OOO D OTHER Crime 104897482 03/13/09 03/13/10 $1,000,000 ~""""~;~ ~'~ ' 3RD Party Covg. ~ Emp. Theft [~~/_ ~~1 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ~] C^ ~ I"~ Job Location: ACC Job# 1526- JP Morgan Chase: 1460 Route 9, Wappingers nGV V Falls, NY. The following are included as additional insureds as respects general liability as required by written contract: Eric Unterreiner, 10 APR 0 6 ?00 Ellens Way, Wallkill, NY 12589 and Stephanie Unterreiner, 19B Stout Court, Poughkeepsie, NY 12601. T~~~~ (;L~R~ CERTIFICATE HOLDER CANCELLATION 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 ~_ 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. AUTHORIZED REPRESENTATIVE i'ce` ACORD 25 (2001108) 1 of 2 #S229826/M229821 ~' 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-S (2001/08) 2 of 2 #S229826/M229821 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 212.279.3700 Adelhardt Construction Corporation 1 c. NYS Unemployment Insurance Employer Registration 241 West 30th Street Number of Insured 4th Floor 1584059 New York, NY 10001 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 3c. Policy effective period: Wappingers Falls, NY 12590 02/06/09 to 02/06/10 4. Policy covers: a. Q 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 By (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 "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 completion to the Workers' Compensation Board, DB Plans Acceptance Unit, 20 Park Street, Albany, New York 1220'7. 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)