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HomeMy WebLinkAbout1465 Ackerly Pond Ln Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * Date: 04/28/22 Receipt#: 297341 Quantity Transactions Reference Subtotal 1 Excavation Permits 1573 $500.00 Total Paid: $500.00 Notes: Payment Type Amount Paid By CK#11132 $500.00 Center, Island Services Inc Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Center, Island Services Inc 67 Sycamore Street Patchogue, NY 11772 Clerk ID: LYNDAR Internal ID: 1573 • I ermit No. rj 1 TOWN OF SOUTHOLD �����, ]HIGHWAY DEPARTMENT Peconic Lane Peconic,New York 11958 1 (631)765-3140 APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR PLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance o an Excavation Permit P suant to Chapter 237 of the Code of the Town of Southold,Suffolk County,New York,and other applicable law;,ordinances or re PLICATION for each individual contiguous excavation project herein described. The applicant agrees to comply with all applicable laws, or finances,codes and regulations,the attached"General Conditions of Permit"and"Special Conditions",if any an to pennit authorized in I ctors to make necessary inspections of the job site. P nt or T e QJ— Name of Applicant Phone Number Address of Applicant - 2. 63 7i--:- Name of Contractor Phone Number Address of Contractor 3. / 77 Z-- Name —Name ofProperty Owner Requesting Service(f applicable) Address of Owner 4 �p-� lame `^ Work Description and Location(Street Number,Hamlet,Cross Street) (a) Is construction located within 75 feet of tidal wetlands? *Yes No *If yes,other Town permits may be required. - NOTE: All information requested by this � - Application/Permit Form is Si rre of Applicant Required for a complete application? f Date 5. (a) Attached plot plan to reasonably and adequately describe the proposed work. Provide accurate schematic sit plan showing the location of all proposed excavations and relationship to adjoining prenuses,public streets or areas,and give a det tiled description of all site and pavement restoration work. (b) Attach all other necessary permits and licenses for this project. (c) Work covered by this application may not commence before issuance of a Highway Excavation Permit by thE Town Clerk. 6. Tax Map No.: District 1000 , Section BlockSS , Lot 7. Starting Date: � Completion Date: f S. Work Schedule: Lhasa Completion Date Excavation _ Work Sc l edule Facility In§tallation iJ;� j Musbe—provided Backfill&:Completion for consideration as a Pavement Replacement 02 ,j/en4� Complete(Application. 9. Under which authority is application being made: r—,4,6,J, , See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work: $ 11. Remarks: D-39 1 of 3 I . Insurance Coverage:(Attach Copy) (a) Insurance Company: 17 r&,� (b) Policy#: / �� (c)State whether policy of certification on file with the Highway Department: (d)Coverage required extended to the Town: Any Loss including Bodily injury,property or commercial injury caused by or attributable to the work per ormed: $1,000,000 per Occurrence and$2,000,000 general aggregate. I Security: C,96 (a)Surety Bond®^l j7�v or Certified Check provided in the total Amount of$ (b)Maintenance Bond provided: 2 years or 3Y ears. 1 . Fees for Applications and permits: Basic Application Fee for Each Project Location - $500.00 A Project Location-would include each Bell Hole and/or every road opening or excavation within 50'Radius whether or not they may be inter-connected by open trench or directional boring. Y The total number of Project Locations shall be subject to the approval of the Highway Superintend ent. Al. � /Service Connections excavations @$50.00 $ No. ----- A2• ?�/Additional Excavations same service @$20.00 $ No. _ B. Trench Excavations 18"in depth or less Total Lineal Footage of Excavation; L.F.@$10.00 $ C. Trench Excavations 18"in depth to 5'in dept4 Total Lineal Footage of Excavation; C--" L.F.@$30.00 $ D. Trench Excavations 5'in depth and over Total Lineal Footage of Excavation; L.F.@$50.00 $ E. 0 Utility Repair Excavations @$1,000.00/Each $ N CJ Additional Repairs of Same Service @$500.00/Each $ No. F. Official Notice to public utilities-proof must be provided and TOTAL$ 040 Shall be attached to this application prior to issuance of permit. M Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation perm t to: in accordance it this application and subject to the"General Conditions"and"Special Conditions"of permit(if any)attached hereto• SUPERINTENDENT OF HIGHWA S TO OF SOU LD,NEW YORK y o tJt1JU NI �L , 606bW.N _ Date Date Received by the Town Clerk o1� Date Permit Issued L 2 2— Permit No. 573 NOTE: Permit expires one(1)year from date of issuance. No work to start without 24 hour notice to Superintendent of Highways. Permit must be available at all times for inspection,on site,during construction. D 39 2 of 3 Copy Distribution: L Permit# J Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings(use code) Applicant Notified 1 St 2nd 3 rd 4th (To Permit Clerk) REMARKS CODE IB Improper Barricades IL Improper Lights ST Sunken Trench or Excavation UTM Unable to Measure(due to backfilling) BUC Building Under Construction WIP Work In Progress DB Improper Backfill(too high,not sufficient) HFS Inspector Holding for Final Settlement of Excavation RFR Ready for Repair " D-39 3 of GENERAL CONDITIONS OF PERMIT APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR I. Permittee's Contractors to Comply with Permit Requirements: The Permittee is responsible for informing its independent contractors, employees,agents and assigns of their responsibility to comply with this permit, including all special/site specific and general conditions imposed by the Highway Superintendent while acting as the permittee's agent with respect to the permitted activities, and such persons shall be required to comply with all permit requirements. 2. No Right to Trespass or Interfere with Private Property Rights: This permit does not convey to the permittee any right to trespass upon the lands of adjacent property owners in order to perform the permitted work nor does it authorize the impairment of any rights,title, or interest in real or personal property held or vested in a person not a party to the permit. 3. Protection of the Highway and Future Highway Maintenance: If future operations or highway maintenance projects by the Town of Southold require an alteration in the position of the utility, structure or work herein authorized, or if,in the opinion of the Highway Superintendent the work performed under this permit shall cause unreasonable obstruction to required highway maintenance or endanger the health, safety and/or welfare of vehicular or pedestrian traffic,this permit shall be revoked and the utility, structure,fill,excavation,or other modification of the highway hereby authorized shall not be completed. Additionally,the permit may be revoked if the Highway Superintendent finds that the issuance of the permit was illegal or unauthorized or that the applicant failed to comply with any of the terms and conditions of the permit or Chapter 237 of the Town Code. 4. Revocation of the Permit by the Highway Superintendent: If the Highway Superintendent deems it necessary to revoke this permit and the project hereby authorized has not been completed,the applicant shall,without expense to the Town and to such extent and in such time and manner as the Superintendent may require, remove all or any portion of the uncompleted utility,structure or fill and restore the site to its former condition. 5. Notice of Commencement: At least 24 hours prior to commencement of the project,the permittee and/or contractor shall notify the Town Highway Department in writing that they are fully aware of and understand all terms and project conditions of this permit. Upon completion of the work,the contractor shall provide photographs of the completed work to the Town Highway Department and request a Final inspection. 6. Storage of Equipment&Materials: The storage of construction equipment and/or materials shall be confined within the project work area and/or adjacent areas where permission/legal access has been obtained in a manner that does not interfere with normal highway traffic. 7. Utility Mark-Outs: The Applicant/Contractor shall be responsible for verification of all existing utility mark-outs and shall take all precautions to protect same. Damage to existing utilities shall be the responsibility of the contractor and shall be repaired at the contractor's expense. 8. Road Closures: All scheduled road closures must first receive written permission from the Southold Town Board prior to closing a road. Temporary lane closures may be permitted with the approval of the Highway Superintendent. This item will included but not be limited to the installation of appropriate signage and flag men to stop and start traffic to allow for single lane traffic. Road Closures due to unforeseen emergencies require immediate notification of the Highway Department and shall be limited to immediate and/or expedited restoration of the Work Zone. 9. No Construction Debris in Road Shoulder Area: All Construction Debris shall be removed from the job site on a daily basis. All stockpiled soil as well as all other project materials that will be staged within the Right-of Way must be delineated with reflective signage or other means to meet the minimum requirements of the NYS DOT Construction Standards. `t of GENERAL CONDITIONS OF PERMIT APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR (Continued) 10. Install,Maintain Erosion Controls: Required Erosion Control Measures (i.e.silt fencing)is to be placed on the downslope edge of any disturbed area. This sediment barrier is to be put in place before any disturbance of the ground occurs and is to be maintained in good functional condition until thick vegetative cover is established. 11. Clean Fill Only: All project back-fill shall consist of clean sand,gravel or soil (NOT asphalt,slag,flyash, broken concrete or demolition debris). All unsuitable soils excavated at the site(i.e.Clay,Bog,etc.)are to be removed from the site and not used to backfill any excavation within a Town Highway. 12. All Areas of Soil Disturbance: All areas of soil disturbance resulting from the approved project shall be stabilized to the satisfaction of the Highway Superintendent immediately following project completion. If the project site remains inactive for more than 48 hours or planting is impractical due to the season,then the area shall be stabilized with straw,hay mulch and/or jute matting until weather conditions favor germination. 13. Backfill&Compaction of all Excavations: Back Fill shall consist of clean fill or soils which exhibit a well-defined moisture density relationship as determined to be in accordance with ASTMD 698. Fill shall be placed in maximum lifts of twelve(12")inches thick and shall be mechanically compacted to a Ninety- five(95%)percent maximum dry density. Suitable hydraulic compaction by water jetting at three-foot intervals will also be permitted subject to a project specific approval by the Highway Superintendent. 14. Restoration of the Road Shoulder Area: All man-made improvements located within existing road shoulder areas must be protected to the greatest extent practical. Items would include but not be limited to driveway&private road aprons, mail boxes,sprinkler systems,trees and ornamental plantings. Excavations through driveways and private road pavements must be reconstructed to meet all requirements of Southold Town Highway Specifications. All pre-existing road shoulder improvements that have been disturbed during construction must be replaced or repaired by the contractor to the satisfaction of the Highway Superintendent. 15. Schematic Plans with all Technical information and Scope of Work:_ To reasonably and adequately describe the proposed work,accurate schematic site plans must be provided to show or indicate all proposed construction activity required under this permit. All Pavement surfaces scheduled for excavation must be saw cut to the full depth of asphalt and/or concrete pavements. Accurate size of bell holes or width of trenching must be indicated by dimension or labeling. This schematic site plan must provide details on all restoration required to meet the requirements of these General Conditions and requirements found in the Southold Town Highway Specifications. 16. Pavement Reconstruction: All Pavement sections must be reconstructed in the following manner; (Note:When Concrete Pavements are Present,Please review Restoration requirements with the Highway Superintendent) a) Complete all back-fill &soil compaction work as needed to provide a suitable sub-base; b) Over-cut existing asphalt bell hole or trench by twelve(12")inches on all sides; c) Install a compacted lift of 4"thick Stone Blend base(RCA Blend must meet NYS DOT Specification); d) Install a two and one half(2.5")inch compacted lift of Asphalt Base Course; e) Install a one and one half(1.5")inch of Asphalt(Type 6)Wearing Course. (Provide AC at all joints) All work listed herein must meet the minimum requirements of the Southold Town Highway Specifications. 17. TrenchinIZ of Pavement Surfaces Exceeding One Hundred (100') Feet in Length: All trenching of pavement surfaces exceeding 100' in length must first be reconstructed to meet the requirements of Item # 16 as noted above. Once all pavement reconstruction is completed to the satisfaction of the Highway Superintendent,the entire road section and/or width of road over the entire length of trench shall be repaved with a two(2") inch lift of Asphalt(Type 6)Wearing Course(Typical,shoulder to shoulder). ' 0-f s (�el� aJ1S) OF 77 Center Island Services - ---i- - -- } - 67-Sycamore - Patchogue, NY 11-772-- --- -- - Crfiice: (631) 475-50- - - Fax:(631)-475-883-0- -.- C®ratact:Sa[Cipolla- - - --- ----- - - - - —, -- - --f- - . .-Cell:-(631)-774-8599-- s - - --- ---- -- -- - Cablevisip n�ect.#:_- I_.�,7 7 - -- - ------ -- --- T W. 1—¢ f ;5. �<<J..._ ._..��._. . •r' -. �Jj� W i10 Results i . Lt I 1 .a x : rt • .'I .J�ri.r,n� • `�• a �gg ,b.E :rr �� P . , �`' • • ��•;rs��� ` �� 1 } Md f i. •r OP 10 t f • ' i �• +i I Please replace 460'span of650MC2 UG feeder. From outputof^ • X' PBA in ped,under street,to input of 14 term tap on right,down • ±• private driveway.Crosses road,and one gravel driveway. First + ped on right down private driveway. I replaced first feet of �� •• a input of output of PBA.Still has a fault 6'below grade on output �• •• feed to term 14. Needs replacement. 20m •+ i — ------- — --- - Y Center island Services 67 Sycamore Street Patchogue, NY 11772 'Office: (631) 475-5600 Fax: (631) 475-8830 ®ntact: Sal Cipoila Cell: (631) 774-8599 Cablevision Project M5 1 I ?3 7 Z- i Ac Z® CERTIFICATE OF LIABILITY INS F04/0 RANCE DYY) �� I 04/06/202/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO R GTS UPON THE-CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER TI IE1 COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETW EN 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain polic es 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; Jenni r Heiser Nicholas Devito Agency, Inc. PHONE , (631)5 9!6388 No): (631)509-0099 449 Route 25A E-MAIL@ ---g-y AODRts$; jennif 'r _devitoa enc .com Mount Sinai, NY 11766 INS RER S AFFORDING COVERAGE NAIC# INSURERA: Atlant c1casualtv Ins. Co. 42846 INSURED INSURER B: Merchants Mutual Ins.Co. 23329 Center Island Services Inc. INSURER C: 67 Sycamore St. INSURER D Patchogue, NY 11772-2874 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:- 00020246-335732 REVISION NUMBER: 30 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 ORVIER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DES RIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY P kID CLAIMS. ILTR TYPE OF INSURANCE ADDL SUER POLICY EFF OUC POLICY NUMBER MM/DD M DY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY Y L302000845-0 10/03/2021 0/03/2022 EACH OCCURRENCE $ 5,000,000 DAMAGE INTE CLAIMS-MADE Fx]OCCUR PREM SES Ea occu enc.' $ 60,000 MED EXP(Any one person) $ 5 000 PERSONAL&ADV INJURY $ 5,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 X POLICY❑JECTPRO- LOC PRODUCTS- $ 5,000,000 OTHER: $ B AUTOMOBILE LIABILITY CAP1079949 10/03/2021 0/03/2022 E°eacIdeDISINGLE LIMIT $ 1 000 000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY Per accid nt $ $ UMBRELLA LIA I OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I ,T DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached if more pace Is required) Town of Southold Is included as additional insured as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF I HE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 275 Peconic Lane Peconic, NY 11958 AUTHORIZED RE RESENT TIVE J-H ©198 -2015 ACORD CORPORATION. All rights reserved. Af►nDn 019 fenecr 12% TM- AP%^Mr,----- --- --- ---°---- -...__ .I-____ -. . .. ... -..--•---- • -- •--- i r-' NRK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSAT ON INSURANCE COVERAGE Board Ia.Legal Name&Address of Insured(use street address only) 1b.Business Telepl one Number of Insured Center Island Services Inc. 631-475-5136o 67 Sycamore Street Patchogue, NY 1.1772-2874 1c.NYS Unemployn iefit Insurance Employer Registration Number of Insured I Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 11-343633 I 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance,Carrier (Entity Being Listed as the Certificate Holder) Property & asualty Ins. Co. of Hartford Town of Southold 3b.Policy Number f Entity Listed in Box"'I a" 275 Peconic Lane Peconic, NY 11958 12WECAKIDDRY 3c.Policy effective eriod 03/21/23122 to 03/21/2023 i 3d.The Proprietor, artners or Executive Officers are included.( my check box if all parinersiof(Icers included) ® all exclude J or certain partnersioffirers excluded. This certifies that the insurance carrier indicated above in box 7'insures the business rE ferenced above in box 1 a"for workers' compensation under the New York State Workers'Compensation Law.(To use this fori n,INew York(NY)must be listed under Item 39 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 must notify the above certificate holder and the Workers'Compen ation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonp yrnent of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices ma be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carriew or its licensed agent,or until the policy expiration date listed In box'1c;",whichever is earlier. This certificate is Issued as a matter of information only and confers no rights upon file c rtjficate holder.This certificate does not amend, extend or after the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. I This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy Is in effect. I Please Note:Upon cancellation of the workers'compensation policy indicated on his form, if the business continues to be named on a permit,license or contract issued by a certificate holder,the businesi njust provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof tha t titre business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Liw, Under penalty of perjury,I certify that I am an authorized representative or license J agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Nicholas Devito (Print nem a: ���or f co d• surance carrier) do r k � Approved by: (signature) i(Date) I Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier. 631-509-6388 Please Note:Only insurance carriers and their licensed agents are authorized to i sue Form C-105.2.Insurance brekers are NQT— authorized to issue it. C-105.2(9-17) www.wcb.ny.gov i voRK Workers' CERTIFICATE OF INSURANCE VERAGE TATE Compensation Board NYS DISABILITY AND PAID FAMILY LEAVIE BENEFITS LAW I PART 1.To be completed by NYS disability and Paid Family Leave benefits card rior licensed insurance agent of that carrie 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Teleph ne Number of Insured CENTER ISLAND SERVICES,INC. 631-475-5600 I 67 SYCAMORE STREET PATCHOGUE,NY 11772 i 1c.Federal Employer Identification Number of Insured or Social Securi Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 113436332 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint LI a Insurance Company Town of Southold 275 Peconic Lane 3b.Policy Number of Entity Listed in Box"la" Peconic, NY 11958 DBL43248 3c.Policy effective peri(d 01/01)2022 to 12/31/2022 4. Policy provides the following benefits: ® A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: © A.All of the employer's employees eligible under the NYS Disability and Paid Family Lealu a Benefits Law. B.Only the following class or classes of employer's employees: ` i 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 and/or Paid Family Leave Benefits insurance coverage as described a ove. -f Date Signed 4/6/2022 By �jj(r -& (Signature of insurance carrier's authorizedrepreser tative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are 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,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd.8 of the NYS Disability and Paid Family Leave Benefits Law: It must be emailed to PAU@wGb.ny.gov or it can-be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit,PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (only if B)x 4B,4C or 58 have been checked) State of New York Workers' Compensation Boa d According to information maintained by the NYS Workers'Compensation Board,the ab ve-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compens tion Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS I Alo,rkers'Compensation Board Employee) Telephone Number Name and Title Please Note.Only insurance carriers licensed to write NYS disability and paid family leave benefit insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers ar NOT authorized to issue this form. 68.120.1 (12.21) DB-120.1 (12-21)