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HomeMy WebLinkAboutDrainage Projects - Cedar Dr, Willow Dr, Cedar Dr S § " RESOLUTION 2023-689 ADOPTED DOC ID: 19378 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2023-689 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON AUGUST 15,2023: RESOLVED that the Town Board of the Town of Southold hereby accepts the proposal of Brian V. Klug Landscaper,Inc. dated August 2, 2023 in the amount of$14,500.00 for the drainage projects on Cedar Drive,Willow Drive and Cedar Drive South; and be it further RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs Supervisor Scott A. Russell to execute an Agreement between the Town of Southold and Brian V. Klug Landscaper, Inc. in the total amount of$14,500.00, subject to the approval of the Town Attorney. Denis Noncarrow Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Jill Doherty, Councilwoman SECONDER:Brian O. Mealy, Councilman AYES: Nappa, Doroski, Mealy,Doherty,Evans, Russell 0 cry Zr O ® � Office of the Town Attorney Town of Southold Town Hall Annex, 54375 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone : 631-765-1939 Facsimile: 631-765-6639 MEMORANDUM To: Denis Noncarrow, Town Clerk From: Missy Mirabelli Secretary to the Town Attorney Date: September 8, 2023 Subject: Brian V. Klug Drainage project- Cedar Dr, Willow Dr and Cedar Dr South, East Marion With respect to the above-referenced matter, I am enclosing the original Agreement together with the Resolution. If you have any questions regarding the enclosed, please do not hesitate to call me. Thank you. /mm Enclosures cc: Accounting Engineering 325-1208 — Landscaper,Inc(— q P.O. Box 349, Speonk, N.Y. 11972 August 30, 2023 Town of Southold Office of the Town Attorney Melissa M. Mirabelli 54375 Main Road PO Box 1179 Southold, NY 11971-0959 Re: Drainage Project— Cedar Drive, Willow Drive & Cedar Dr South, East Marion Dear Ms. Mirabelli: Enclosed are two signed Agreements and updated certificates of insurance. Thank you very much. Best regards, Monica Klug, Vice Pres c THIS AGREEMENT made and entered into this of August 2023, by and between Town of Southold (hereinafter referred to as "Town"), a municipal corporation organized and existing under and by virtue of the laws of the State of New York (mailing address: c/o Dennis Noncarrow, Town Clerk, P.O. Box 1179, Southold, New York 11971-0959), party of the first part, and Brian V Klug, Landscaper, Inc. (hereinafter referred to as "Contractor") with an address at P.O. Box 349, Speonk, New York 11972, party of the second part. WITNESSETH: That the Town and Contractor, for the consideration named, hereby agree as follows: 1. PURPOSE. The Contractor shall provide professional services in conjunction with the drainage projects on Cedar Drive, Willow Drive and Cedar Drive South in East Marion,New York. 2. SPECIFIC SERVICES. The Contractor shall perform all the tasks as set forth in the Proposal submitted to the Town dated August 2, 2023 and specifically the scope of work identified at page "1" thereof, a copy of which is attached hereto as Appendix"A"and made a part hereof, for the total sum of$14,500.00. 3. TIME AND ATTENDANCE; COOPERATION BY THE TOWN. The services to be rendered under this Contract shall be completed within two (2) months of execution of the contract. The Town agrees to cooperate with Contractor, as needed, and to provide Contractor with copies of any records, documents and other information needed for performance of this agreement in a timely basis. The Town further agrees to provide Contractor with access to all work areas and appropriate officials and/or employees of the Town, as may be needed in the performance of the agreement. Moreover, both parties understand and agree that mutual accountability and responsiveness is critical to the successful completion of the project, and therefore both shall always use their best faith efforts to be accountable and promptly responsive to each other. 4. COMPENSATION. In payment for the services to be performed hereunder by Contractor, the Town shall make payments to Contractor as follows: (a) For the services to be performed by Contractor pursuant to Paragraph"2" hereof,the Town shall pay Contractor as set forth in the Proposal (Appendix "A"). Contractor shall submit an itemized voucher for work actually completed on a monthly basis to the Town Comptroller. Such voucher shall be due and payable within 45 days after receipt of such voucher, subject to review of the Comptroller and approval for payment by the Town Board. (b) The Town shall process any vouchers received from Contractor as expeditiously as possible. 1 (c) In the event that the Town disputes or objects to any portion of any voucher submitted by Contractor pursuant to this paragraph, the Town shall, within 30 days of the receipt of such voucher, notify Contractor in writing of such dispute or objection. (d) Contractor acknowledges that Contractor is familiar with the requirements of Section 118 of the Town Law which, in effect, prohibits payment of any of Contractor's claims against the Town unless an itemized voucher therefore shall have been presented to the Town Board/Town Comptroller and shall have been audited and allowed by the Town Board/Town Comptroller. 5. TERM OF AGREEMENT; TERMINATION. This agreement shall commence on the Agreement being fully executed and shall terminate upon completion of, and payment for, all the tasks outlined in the Proposal, provided, however, that this agreement shall terminate immediately in the event that (a) Contractor dies; (b) Contractor incurs a disability which makes Contractor unable to perform the services which Contractor is required to perform hereunder; (c) Contractor files a Petition in Bankruptcy Court or a Petition is filed against Contractor in Bankruptcy Court, or Contractor is adjudged bankrupt or makes an assignment for the benefit of creditors; or (d) a Receiver or Liquidator is appointed for Contractor and/or Contractor's property and is not dismissed within 20 days after such appointment or the proceedings in connection therewith are not stayed on appeal within the said 20 days. In the event that Contractor refuses or fails to provide the services required hereunder with due diligence, or fails to-make prompt payment to persons supplying labor for Contractor's services hereunder,or refuses or fails to comply with applicable statutes, laws or ordinances, or is guilty of a substantial violation of any provision of this agreement, the Town shall send Contractor written notice that Contractor has 20 days to cure said default; and if, at the end of said 20-day period, Contractor has not cured said default, the Town may then terminate this agreement on 7 days'prior written notice to Contractor. Except as prohibited by law,the Town and Contractor hereby waive trial by jury in any litigation arising out of, or connected with, or relating to this Agreement. 6. SKILLS OF CONTRACTOR; CONFLICTS OF INTEREST. Contractor represents that Contractor, and any subcontractor performing work under this contract, have the requisite skills and experience to perform the services hereunder. 7. INDEPENDENT CONTRACTOR STATUS. Contractor and the Town agree that in the performance of Contractor's services hereunder, Contractor is an independent contractor and shall not be deemed to be an employee or agent of the Town for any purpose whatsoever. The Contractor shall assume all blame, loss and responsibility of any nature by reason of neglect or violation of any federal, state, county or local laws, regulations or ordinances. i L 8. CONTRACTOR'S INSURANCE The Contractor and any and all subcontractors performing work, labor or services shall not commence work under this Contract until it has obtained all insurance required under this paragraph and such insurance has been approved by the Town. (a) Compensation Insurance: The Contractor shall take out and maintain during the life of this Contract Workers' Compensation Insurance for its employees to be assigned to the work hereunder. (b) Liability Insurance: The Contractor shall take out and maintain during the life of this Contract such general liability, property damage, and commercial auto liability insurance as shall protect it and the Town from claims for damages for personal injury, including accidental death, as well as from claims for property damage which may arise from operations under this Contract. The amounts of such insurance shall be as follows: 1. General liability insurance in an amount not less than $2,000,000 for injuries, including wrongful death to any one person and subject to the same limit for each person, in an amount not less than $5,000,000 on account of any one occurrence. 2. Property damage insurance in an amount not less than $500,000 for damage on account of all occurrences. The Town shall be named as a certificate holder and an additional insured on all policies of insurance and shall furnish proof of same to the Town Attorney prior to its commencement of any work under this Agreement. (c) Any accident shall be reported to the office of the Town Clerk as soon as possible and not later than twenty-four (24) hours from the time of such accident. A detailed written report must be submitted to the Town as soon thereafter as possible, but not later than three (3) days after the date of such accident. 9. INDEMNIFICATION Contractor and its subcontractors, agents, servants and employees shall release, indemnify, defend and hold harmless the TOWN, its officers, employees, and representatives from and against any and all demands, liabilities,losses,damages,expenses(including attorney's fees)and judgments for any personal injuries, death, or property damage in any way relating to or arising from this Contract and the services to be performed under this contract. 10. PROHIBITION AGAINST ASSIGNMENT. Contractor is hereby prohibited from assigning, transferring, conveying, subletting or otherwise disposing of this agreement or his right, title or interest in this agreement without prior written consent of the Town. Il. COMPLIANCE WITH STATUTES. Contractor agrees that Contractor will comply with all statutes, ordinances, local laws, codes, rules and regulations which are or may be applicable to Contractor's services, activities and duties set forth in this agreement. 12. NOTICES. Any and all notices and payments required hereunder shall be addressed as follows, or to such other address as may hereafter be designated in writing by either party hereto: To Town: Dennis Noncarrow Town Clerk Town of Southold PO Box 1179 Southold, NY 11971-0959 To Contractor: Brian V Klug,Landscaper,Inc. P.O. Box 349 Speonk,New York 11972 13. WAIVER. No waiver of any breach of any condition of the Agreement shall be binding unless in writing and signed by the party waiving said breach. No such waiver shall in any way affect any other term or condition of this Agreement or constitute a cause or excuse for a repetition of such or any other breach unless the waiver shall include the same. 14. APPLICABLE LAW. This Agreement and the rights and obligations of parties hereunder shall be construed in accordance with and be governed by the laws of the State of New York without regard to conflicts of laws and principles. Contractor hereby submits to the jurisdiction of the Courts of the State of New York for all disputes relating to this Agreement and agrees that venue for all disputes shall be in Suffolk County. 15. COMPLETE AGREEMENT; MODIFICATION. I This Agreement constitutes the complete understanding of the parties. No modification of any provisions thereof shall be valid unless in writing and signed by both parties. IN WITNESS WHEREOF, the Town of Southold has caused its corporate seal to be affixed hereto and these presents to be signed by Scott A. Russell, its Supervisor, duly authorized to do so, and to be attested to by Dennis Noncarrow, Town Clerk, and the Contractor has caused its corporate seal to be affixed hereto ,and these presents to be signed by its President, the day and year first above written. TOWN OF SOUTHOLD By: �d turf Scott A. Russell, Supervisor Brian V Klug,Landscaper,Inc. BY: 124, ria h V f resident STATE OF NEW YORK) COUNTY OF SUFFOLK) ss: On the c)of August in the year 2023 before me, the undersigned, personally appeared Scott A. Russell, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity and that by his signature on the instrument, the individual or the person upon whose behalf of which the individual acted, executed the instrument. Notary Public LAUREN M.STANDISH PUBL OF NEW _ NOTRegist ation No.O01ST6164M Qualified In Suffolk County Commission Expires April 9,20� STATE OF NEW YORK) COUNTY OF SUFFOLK) ss: On the 30 sof August in the year 2023 before me,the undersigned,personally appeared ('/�ny, 6�" ,personally known to me or proved to me on the basis of satisfactory evidence o be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity and that by his signature on the instrument, the individual or the person upon whose behalf of which the individual acted, executed the instrument. LiM Notary Public KIMBERLY HONIG NOTARY PUBLIC,State of New York No.01HSuffol CO Qualified in Suffolk CoUtr, Commission Expires 325-1208 all H . — Landsc:per,Inc.— P.O.Box 349, Speonk,N.Y. 11972 August 2, 2023 ! Town of Southold Michael Collins, P.E. Engineering Department 53095 Main Road Southold, NY 11971 PROPOSAL: Cedar Drive South, Cedar Drive, and Willow Drive, East Marion, NY • Approximately 25' of 18" diameter corrugated metal pipe will be replaced with 15" diameter HDPE between Structure cb1 cedar dr s and Structure cb2 cedar dr s • Approximately 25' of 18" diameter corrugated metal pipe will be replaced with 15" diameter HDPE between Structure cb6 cedar dr and Structure cb7 cedar dr • Structure cb2 willow dr(catch basin) has settled unevenly and must be removed and reset • Approximately 25' of 18" diameter corrugated metal pipe will be replaced with 15" diameter HDPE between Structure cb1 willow dr and Structure cb2 willow dr • The first 10' of 18" diameter corrugated metal pipe exiting Structure cb2 willow dr to the east will be replaced with 15" diameter HDPE. The connection between the new HDPE pipe and the existing corrugated metal pipe will be sealed with concrete. Total: $14,500. • The Southold Town Highway Department will obtain utility mark outs and cut the I asphalt trenches with a road saw prior to the start of construction • The Southold Town Highway Department will provide barriers and signage so that the road can be closed in the vicinity of the project area during construction. • The Southold Highway Department will provide the 15" diameter HDPE pipe for this project • Upon completion of the project, the road must be restored with 6" of compacted RCA to the existing road grade. • The Southold Town Highway Department will provide the RCA • This job DOES NOT INCLUDE asphalt restoration or curb restoration • The contractor is responsible for the disposal of all asphalt debris and excavated materials generated during the course of the project. • This is a prevailing wage job and certified payrolls must be provided with the final invoice. /�� ® DATE(MMIDDIYYYtn CC) CERTIFICATE OF LIABILITY INSURANCE 08/30/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED-BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN 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 policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTNAAME"CT Nate Perry Quinton Insurance PHONE, (800)454-1970 XI No): (585)388-9531 2700 Elmwood Ave E-MAIL Coq ADDRESS: service@quintoninsurance.com INSURERS AFFORDING COVERAGE NAIC# Rochester NY 14618 INSURER A: ERIE INSURANCE CO 26263 INSURED INSURER B: FLAGSHIP CITY INSURANCE COMPANY 35585 Brian V Klug Landscaper,Inc INSURER C: SHELTER POINT 81434 P.O.BOX 349 INSURER D: INSURER E: SPEONK NY 11972-0349 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP POLICY NUMBER MM/DD M DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR PREM SES Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ 5,000 A Y Q32-8120097 08/31/2023 08/31/2024 1 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JECOT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ A AOWNED UT ONLY �/ AUTOS Q08-8130206 Q08-8130206 08/31/2023 08/31/2024 BODILY INJURY(Per accident) $ HIREDX AUTOS ONLY /� AUTOS ONLY PROPERTY DAMAGE $ Peraccldent X UMBRELLALIAB I X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAO CLAIMS-MADE Q32-8170039 08/31/2023 08/31/2024 AGGREGATE $ 1,000,000 DED RETENTION �/ $ WORKERS COMPENSATION /� STATUTE ETH AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 B OFFICERIMEMBER EXCLUDED? FN—] NIA Q91-6000155 07/10/2023 07/10/2024 (Mandatory in If yes,describe under E.L.DISEASE-EA EMPLOYE $ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 Group Short Term Disability� C D255547 06/21/2023 06/20/2024 statutory DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Town of Southold is included as additional insured with respects to the General Liability policy where required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Rd. AUTHORIZED REPRESENTATIVE PO Box 1179 Southold,NY 11971 AS ecEler roaa 1.<.o A INc ©1988-2015 ACORD CORPORATION. All rlghts reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Com NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Brian V Klug Landscaper,Inc P;0. BOX 349 SPEONK,NY 11972-0349 1c. NYS Unemployment Insurance Employer Registration Number of Insured 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 r 11-2906829 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) FLAGSHIP CITY INSURANCE COMPANY Town of Southold 54375 Main Rd. 3b.Policjr Number of Entity Listed in Box"1 a" PO Box 1179 Q96-6100169 Southold,NY 11971 3c.Policy effective period n7/1n/ornn t0 n7mnign24 3d.The Proprietor,Partners or Executive Officers are included.(Only Bieck 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"l a"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 must notify the above certificate holder and the Workers'Compensation Board 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. 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 policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect Please Note:,Upon 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 1 am an authorized representative or licensed agent of the insurance carrier referenced above and that the named Insured has the coverage as depleted on this form. Approved by: Gordon Quinton (Print name of i�auudiorized representative or licensed aqent of insurance carrier Approved by: 4'��. �' iii l r5w"roRt(.an.tvc 08/30/2023 (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: (585)244-9004 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(9-17) www.wcb.ny.gov 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(9-17) REVERSE YORK Workers' CERTIFICATE OF INSURANCE COVERAGESTATE Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured BRIAN V KLUG LANDSCAPER INC 631-369-3620 PO BOX 349 SPEONK, NY 11972 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 112906829 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold 54375 Main Rd. 3b.Policy Number of Entity Listed in Box"1 a" PO Box 1179 DBL255547 Southold, NY 11971 3c.Policy'effective period 06/21/2023 to 06/20/2024 4. Policy provides the following benefits: 0 A.Both disability and paid family leave benefits. ❑ B.Disability benefits only. F1 C.Paid family leave benefits only. 5. Policy covers: ❑X A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of 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 and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 8/30/2023 By �Jdd 4� (Signature of insurance carrier's authorized representative 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 413,4C 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@wcb.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 Box 413,4C or 5B have 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 and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave 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. D113-120.1 (12-21) 11111111°°°1°°°°1°°11°111°1°°°1°°1111111 Additional Instructions for Form D13-120.1 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 1 a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate)to the entity listed as the certificate holder in Box 2. The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is cancelled 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 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. 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 policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This Certificate may be used as evidence of a NYS disability and/or Paid Family Leave benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or Paid Family Leave 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) 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 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 and after January first,two thousand and twenty-one, the payment of family leave 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 and after January first, two thousand eighteen,the payment of family leave benefits for all employees has been secured as provided by this article. D13-120.1 (12-21)Reverse