HomeMy WebLinkAbout2006-2009 New York State Insurance Fund
Workers'Compensation&Disability Benefits Specialists Since 1914
199 CHURCH STREET,NEW YORK,N.Y.10007-1100
Phone (888)997-3863
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
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NORTH FORK ANIMAL
WELFARE LEAGUE INC
PO BOX 297
SOUTHOLD NY 11971
POLICYHOLDER CERTIFICATE HOLDER
NORTH FORK ANIMAL TOWN OF SOUTHOLD
WELFARE LEAGUE INC TOWN CLERK
PO BOX 297 PO BOX 1179
SOUTHOLD NY 11971 SOUTHOLD NY 11971
POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE
Z 673 415-6 628764 08/23/2006 TO 06/01/2009 3/21/2008
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 673415-6 UNTIL 06/01/2009, 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 06/01/2009 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE,
10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE.
NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW
YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE.
THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION.
THIS CERTIFICATE 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.
NEW YORK STATE INSURANCE FUND
DIRECTOR,INSUR'1NCE FUNr' 1F G,
This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling '188)87.5
U-26.3 VALIDATION NUMBER:291985507
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