HomeMy WebLinkAboutARPA - Orient Fire District =oOgUfFO(,yC3 RESOLUTION 2023-482
ADOPTED DOC ID: 19178
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2023-482 WAS
ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON
MAY 23, 2023:
WHEREAS, the American Rescue Plan Act, H.R. 1319 (ARPA)was signed into law in March
of 2021; and
WHEREAS, ARPA modifies provisions of Title VI of the Social Security Act(42 U.S.C. § 801
et seq.); and
WHEREAS, the appropriations under 42 U.S.C. § 803 (b)(2) are titled State and Local Fiscal
Recovery Funds (SLFRF); and
WHEREAS, the Town of Southold, New York, has received its allotment of the Fiscal
Recovery Funds (SLFRF); and
WHEREAS, 42 U.S.C. § 803 permits ARPA funds to be expended for public services, including
fire departments and emergency services, Infrastructure, equipment and apparatus for the
purpose of bolstering public sector capacity to deliver critical services; and
NOW, THEREFORE, BE IT RESOLVED, that the Town of Southold hereby elects to
distribute the sum of$50,000.00 of ARPA funds to each of the Fire Departments serving the
residents of the Town of Southold to be utilized for the purchase of equipment and apparatus for
the purpose of bolstering public sector capacity to deliver critical services; said funds to be paid
to the Fishers Island Fire District; Orient Fire Department; the East Marion Fire Department; the
Greenport Fire Department; the Southold Fire Department, the Cutchogue Fire Department and
the Mattituck Fire Department; and be it further
RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs
Supervisor Scott A. Russell to execute all documents to facilitate the transfer of such funds.
Denis Noncarrow
Southold Town Clerk
RESULT: ADOPTED [UNANIMOUS]
MOVER: Greg Doroski, Councilman
SECONDER:Louisa P. Evans, Justice
AYES: Nappa, Doroski, Mealy, Doherty, Evans, Russell
O
r
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: October 17, 2023
Subject: ARPA Agreement East Marion Fire Dept
With respect to the above-referenced matter, I am enclosing an original, fully executed
Agreement for your records 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
r
ARPA SUB RECIPIENT GRANT AGREEMENT
This Grant Agreement (this"Agreement") is entered into by and between The Town of Southold,
(the"Town") and Orient Fire District(the "Grantee"), a non-profit entity providing public services,
including emergency response,fire protection, emergency medical services, equipment and apparatus,
training and education for the purpose of bolstering public sector capacity to deliver critical services.
WHEREAS,the Town is the recipient of a grant(as more fully described in Exhibit A,the"ARPA
Grant") made available under the American Rescue Plan Act("ARPA")from the United States Treasury;
WHEREAS,the Town is desirous of distributing such funds to the Grantee to be utilized for the purchase
of equipment and apparatus to assist in the delivery of required critical services in the amount identified
herein and on the terms and conditions stated herein; and
WHEREAS,the Grantee is willing to accept the such distribution and become a sub-recipient of the ARPA
Grant, on the terms and conditions stated herein.
NOW,THEREFORE, in consideration of the premises and the mutual covenants herein contained,
the parties agree and bind themselves as follows:
ARTICLE I -REPRESENTATIONS OF THE GRANTEE
1
Recognizing that the Town is relying hereon,the Grantee represents, as of the date of this
J
Agreement, as follows:
(a) Organization; Power, Etc.The Grantee is a non-profit entity duly established under the laws of the
State of New York with full legal right and power to authorize, execute, and deliver this Agreement,to
receive each Grant,to undertake and implement the use of Grant funds as described herein and to carry
out and consummate all transactions contemplated by the foregoing(including without limitation the
recordkeeping and reporting described herein);
(b)Authority.The Grantee has duly and validly authorized the execution and delivery of this
Agreement and has or will have so authorized the execution of each Application,and all
approvals,consents,and other governmental or corporate proceedings necessary for the
execution and delivery of the foregoing or required to make this Agreement the legally
i
binding obligation of the Grantee that it purports to be, in accordance with its terms, have
been obtained or made.The representatives of the Grantee executing this Agreement have
all necessary power and authority to execute this Agreement and to bind the Grantee to the
terms and conditions herein.
(c) No Litigation. No action,'suit, proceeding, inquiry or investigation, at law or in equity,
before or by any court, public board or body,other than as disclosed to the Town in
writing, is pending or,to the knowledge of the authorized representatives of the Grantee
executing this Agreement, or threatened either seeking to restrain or enjoin the execution and
delivery of this Agreement,the services provided or contesting or affecting the validity of this
Agreement; and neither the non-profit status of the Grantee nor the title to the office of any authorized
representatives of the Grantee executing this Agreement, is being contested.
(d),No Conflicts.The authorization, execution and delivery of this Agreement will not constitute a breach
of, or a default under, any law,ordinance, resolution,agreement, indenture or other instrument to which
the Grantee is a party or by which it or any of its properties are bound.
(e)SAM Registration.Grantee is registered with the System for Award Management(SAM)
and confirms that the Federal UEI number listed in Exhibit A is the correct such number for the Grantee
as of the date hereof.
(f) Binding Agreement.This Agreement is,or when executed and delivered will be,the legal,
valid, and binding obligation of the Grantee, enforceable in accordance with its terms,
subject only to limitations on enforceability imposed in equity or by applicable bankruptcy,
insolvency, reorganization, moratorium or similar laws affecting creditors' rights
generally.
(g) Information Submitted.All information, reports, and other documents and data submitted
to the Town in connection with this Agreement is true, correct and complete in all material respects.
(h) Ratification. By executing this Agreement,the Grantee(i)affirms and ratifies all
statements, representations and warranties contained in all written documents submitted to the Town
in connection with this Agreement and (ii) agrees that on each date, if any,that any additional
documentation is attached hereto and made a part hereof, it will be deemed to have
affirmed and ratified all such statements, representations and warranties.
ARTICLE II -THE GRANT
2.1 Grant Amount: $50,000.00 The Town agrees to make and the Grantee agrees to accept,on the terms
and conditions stated in this Agreement,the Grant Amount specified herein.
2.2 Project and Schedule
(a) Grant Purpose. Each Grant is being made solely to reimburse the Grantee for actual expenses
incurred in the purchase of equipment and apparatus for the purpose of bolstering capacity to deliver
firematic and critical care services to residents of the Town of Southold.
(b) Grant Expenditure Schedule.All grant amounts must be expended by December 31,2026.
All Grant proceeds that remain unexpended shall be returned to the Town.
2.3 Grant Award Package
In connection with the execution and delivery of this Agreement,each of the following conditions
shall be satisfied (all documents, certificates and other evidence of such conditions are to be satisfactory
to the Town in its sole and absolute discretion).
(a) Executed Grant Agreement.The Town shall receive a duly executed original of this Agreement.
(b) Expiration of Offer. Each Grant, and the obligation of the Town to disburse such Grant,
or any portion thereof,shall expire ninety(90) days from the date the Grantee was presented with a
copy of this Agreement, unless the Grantee duly executed said Agreement and returned same to the
Town. The Town, in its sole and absolute discretion, may approve one or more extensions
to the expiration of the offer of any Grant.
ARTICLE III -AFFIRMATIVE COVENANTS
3.1 Use of Disbursements
The Grantee shall expend the Grant funds only for eligible expenses as outlined herein,subject to Article
II hereof.The Grantee shall be responsible for compliance with,and shall comply in all material respects
with, all applicable laws and regulations,whether or not such laws or regulations are expressly
referenced herein.
3.2 Reporting and Compliance with Laws
(a)The Grantee shall comply with all reporting requirements set forth in Schedule A hereto.
In addition,the Grantee agrees that all Grant monies shall be expended in full compliance with all
applicable provisions of federal, state and local law and all regulations thereunder.
(b)Without limiting the generality of Section 3.2(a),the Grantee covenants to comply in all
respects with all applicable laws, regulations and rules regarding bidding, procurement,
employment and anti-discrimination, including,without limitation,Title VI of the Civil
Rights Act of 1964,which prohibits recipients of federal financial assistance from
excluding from a program or activity, denying benefits of, or otherwise discriminating
against a person on the basis of race, color, or national origin (42 U.S.C. § 2000d et seq.), -
as implemented by the Department of the Treasury's Title VI regulations,31 CFR Part
22,which are herein incorporated by reference and made a part of this contract(or
agreement).Title VI also includes protection to persons with "Limited English
Proficiency" in any program or activity receiving federal financial assistance,42 U.S.C.
§ 2000d et seq., as implemented by the Department of the Treasury's Title VI regulations,
31 CFR Part 22, and herein incorporated by reference and made a part of this Agreement.
(c) Grantee certifies that it has read and understood its obligations with respect to compliance
with the non-discrimination requirements in this Agreement(including,without limitation,
Schedule B hereto), certifies that it is in compliance with such requirements, and covenants
to remain in compliance at all times while this Agreement is in effect.
3.3 Recoupment and Costs
The Grantee acknowledges that it is responsible for compliance with this Agreement and all state
and federal laws and regulations applicable to the Grant(s)funding source.Any breach of this
Agreement and/or failure to comply with such law or regulation may result in all or a portion of the
Grant becoming subject to recoupment(including,without limitation,as described in each Application).
If any portion of the Grant is subject to recoupment,the Town will notify the Grantee in writing and the
Grantee shall promptly and, in any event,within 10 days of receiving such notice, return such Grant
proceeds (including both any unexpended portion and funds equal to the portion expended) and any
interest earnings thereon. In addition, Grantee shall be responsible for, and hereby agrees to promptly
pay or reimburse the Town for all costs incurred by the Town, its employees,officers and agents
(including without limitation, attorneys'fees) related to or arising out of such recoupment including,
without limitation, costs of any related investigation, audit and/or collection efforts.
3.4 Indemnification
To the fullest extent permitted by law,the Grantee agrees to indemnify and hold harmless the
Town and all of its employees,officers, and agents (collectively, "Indemnified Persons")from and against
any and all losses,costs, damages,expenses,judgments, and liabilities of whatever nature(including,
but not limited to,attorneys', accountants' and other professionals'fees and expenses, litigation and
court costs and expenses, amounts paid in settlement and amounts paid to discharge judgments and
amounts payable by Indemnified Persons relating to or arising out of(i)the actual or alleged failure of
the Grantee to comply with the terms of this Agreement or with any other requirement or condition
applicable to the federal grant with which any Grant is funded or(ii)the operation or undertaking of
each Project; provided that no indemnification shall be required of an Indemnified Person to the extent
such losses are determined by the final judgment of a court of competent jurisdiction to be the result of
the gross negligence or willful misconduct of such Indemnified Person.Such indemnification includes,
but is not limited to, costs arising from third-party claims.The provisions of this Section shall survive the
termination of this Agreement, and the obligations of the Grantee hereunder shall apply to losses or
claims whether asserted prior to or after the termination of this Agreement. In the event of failure by
the Grantee to observe the covenants,conditions and agreements contained in this Section, any
Indemnified Person may take any action at law or in equity to collect amounts then due and thereafter
to become due, or to enforce performance and observance of any obligation, agreement or covenant of
the Grantee under this Section.The obligations of the Grantee under this Section shall not be affected by
any assignment or other transfer by the Town of its rights or interests under this Agreement and will
continue to inure to the benefit of the Indemnified Persons after any such transfer.The provisions of this
Section shall be cumulative with and in addition to any other agreement by the Grantee to indemnify
any Indemnified Person.
3.5 Federal UEI
The Grantee shall maintain an active UEI registration at all times while this Grant Agreement is
in effect.
3.6 Recordkeeping.
The Grantee shall maintain accounts and records with respect to the utilization of all Grant funds in
accordance with generally accepted accounting principles as issued from time to time by the
Governmental Accounting Standards Board (GASB). Grantee shall keep and maintain all financial records
and supporting documentation related to Grant expenditures for a period of seven years after all Grant
proceeds have been expended or returned to the Town.Wherever practicable,Grantee shall collect,
transmit, and store such records in open and machine readable formats. Grantee agrees to make such
records available to the Town or to the United States Treasury upon request, and to any other authorized
oversight body, including but not limited to the Government Accountability Office (GAO),the Treasury's
Office of Inspector General(OIG) and the Pandemic Relief Accountability Committee (PRAC).Grantee
agrees to make such accounts and records available for on-site inspection during regular business hours
of the Grantee and permit the Town,the United States Treasury or any other such authorized oversight
body to audit,examine, and reproduce such accounts and records,and to make audits of all contracts,
invoices, materials, payrolls, records of personnel, data, and other information relating to all matters
covered by this Agreement.
The Grantee shall permit the Town or any party designated by it upon reasonable prior notice to
the Grantee to examine and to inspect and,without limiting the generality of the previous paragraph,to
make copies of any accounts, books and records of the Grantee pertaining to Grant expenditures.
3.7 Single-Audit
i
The Grantee acknowledges that by accepting the Grant(s) it is a sub-recipient of federal financial
assistance under the federal Single Audit Act of 1984, as amended (the"SAA").The Grantee further
acknowledges that to the extent it expends an aggregate of$750,000 in federal awards(including, but
not limited to the Grant(s)) in a fiscal year, it will be subject to an audit under the SAA and its
implementing regulations at 2 CFR Part 200,Subpart F.
I
ARTICLE IV-TERMINATION AND REMEDIES
4.1 Termination
r
(a)Termination by the Town.The Town, in its sole and absolute discretion, may terminate
this Agreement or any one or more Grants hereunder:
(i) if the Grantee has breached any provision of this Agreement(including without
limitation reporting requirements in Schedule A hereto) or has failed to comply
with any applicable state or federal law or regulation applicable to any Project
and/or any Grant; or
(ii) if any representation or warranty made by the Grantee in any Application, this
Agreement, or any certification or other supporting documentation thereunder or
hereunder shall prove to have been incorrect in any material respect at the time
made.
(b) Notice of Termination.The Town shall provide the Grantee with written notice of
termination of this Agreement or any one or more Grants,setting forth the reason(s)for
termination.The termination of this Agreement or any one or more Grants shall be
effective as of the date such notice of termination is sent by the Town.
(c) Effect of Termination. Upon termination of this Agreement or any Grant,the Grantee shall
reimburse the Town for all costs and disbursements of the Grant(s)terminated on a
schedule to be negotiated in good faith between the Town and the Grantee, but in no event
more than 60 days from the date of such termination.
4.2 Term
This Agreement shall remain in effect until one of the following events has occurred:
(a)The Grantee and the Town substitute this Agreement with another written agreement;
(b)All of the Grantee's obligations under this Agreement have been discharged, including,
without limitation,any obligation to reimburse the Town for disbursements of the
Grant(s); or
(c)This Agreement has been terminated pursuant to the provisions of Section 4.1 hereof.
ARTICLE V- MISCELLANEOUS
5.1 Notices
All notices, requests and other communications provided for herein including,without limitation,
any modifications of, or waivers, requests or consents under,this Agreement shall be given or made in
writing and delivered, (i) in the case of the Town,to the Town Clerk, 53095 Route 25A,Southold, New
York 11971, and (ii) in the case of the Grantee,to the Orient Fire District, 23300 Main Road, Orient, New
York, 11957; or, as to either party, at such other address as shall be designated by
such party in a notice to each other party. Unless otherwise provided herein, receipt of all such
communications shall be deemed to have occurred when personally delivered or, in the case of a mailed
notice, upon receipt, in each case given or addressed as provided for herein.
5.2 No Waiver
No failure or forbearance on the part of the Town to exercise, and no delay in exercising, any
right hereunder shall operate as a waiver thereof nor shall any single or partial exercise by the Town
of any right hereunder preclude any other or further exercise thereof or the exercise of any other right.
Conditions, covenants,duties and obligations contained in this Agreement may be waived only by
written agreement between the parties.
5.3 Governing Law
This Agreement shall be construed under, and governed by,the laws of the State of New York.The
Grantee agrees to bring any federal or state legal proceedings arising under this Agreement in which the
Town is a party in a court of competent jurisdiction within the County of Suffolk. This section shall not
be construed to limit any other legal rights of the parties.
5.4 Successors and Assigns
This Agreement shall be binding upon and inure to the benefit of the Grantee and the Town and
their respective successors and assigns, except that the Grantee may not assign or transfer its rights or
obligations hereunder without the prior written consent of the Town.
5.5 Complete Agreement;Waivers and Amendments
All conditions, covenants, duties and obligations contained in the Agreement may be amended only
through a written amendment signed by the Grantee and the Town unless otherwise specified in this
Agreement.
5.6 Headings
The headings and sub-headings contained in the titling of this Agreement are intended to be used
for convenience only and do not constitute part of this Agreement.
5.7 Severability
If any term, provision or condition, or any part thereof, of this Agreement shall for any reason be
found or held invalid or unenforceable by any governmental agency or court of competent jurisdiction,
such invalidity or unenforceability shall not affect the remainder of such terms, provisions or conditions
nor any other term, provision or condition, and this Agreement shall survive and be construed as if such
i
invalid or unenforceable term, provision or condition had not been contained therein.
5.8 Schedules, Exhibits and Attachments;Counterparts; Electronic Signature
Each schedule, exhibit or other attachment hereto and referred to herein is an
integral part of this Agreement.This Agreement may be executed in several counterparts, each of which
shall be deemed to be an original. Counterparts may be delivered via facsimile, electronic mail (including
pdf or any electronic signature complying with the U.S.federal ESIGN Act of 2000 and related state law)
or other transmission method and any counterpart so delivered shall be deemed to have been duly and
validly delivered and be valid and effective for all purposes.
5.9 Further Assurances
Grantee agrees that it will,from time to time, execute,acknowledge, and deliver,or cause to be
executed, acknowledged, and delivered, such further instruments as may reasonably be required for
carrying out the intention or facilitating the performance of this Agreement.
5.10 Third-Party Beneficiaries
This Agreement is exclusively between the Town and the Grantee, and does not, nor is intended,
to create any privity of contract with any other party not a party hereto other than the Indemnified
Persons, nor to imply a contract in law or fact.The Town is not obligated to disburse grant funds on any
contract,or otherwise, between the Grantee and any other party, nor intends to assume, at any time,
direct obligations for payment for work,goods, or other performance under such contracts.The
obligation to pay any amounts due under such contracts is solely the responsibility of the Grantee.
Nothing herein, express.or implied, is intended to, or shall confer upon, any other person any right,
benefit, or remedy of any nature whatsoever under or by reason of this Agreement between the Town,
the Grantee and the Indemnified Persons.
IN WITNESS WHEREOF,the parties hereto have caused this Grant Agreement to be duly executed as of
the day of August, in the year 2023.
TOWN OF SO HOLD
By: �,u7
Name: Scott A. Russell
Title:Supervisor / 1
Date:
ORIENT FIRE DISTRICT, GRANTEE
NaMEr, hSg S
Date:
Schedule A-1
SCHEDULE A
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`. n Attnrneyig Offid@
ORIENT FIRE DISTRICT
23300 Main Road, Orient, NY 11957 �sE���®
631-323-2445 • FAX 631-323-9706
orientfired@optonline.net
OCT 13 2023
The Unique Entity ID (UEI) for the Orient Fire District is: Town Attorney's Office
HGFKLZ2F1QT9
Form Request for Taxpayer Give Form to the
(Rev.October 2018) Identification Number and Certification requester.Do not
Department of the Treasury send to the IRS.
Internal Revenue Service ►Go to www1irs.gov/FormIN9 for instructions and the latest information.
1 Name(as wn on your income tax return).Name is required on this line;do not leave this line blank.
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2 Business name/disregarded entity name,if different from above
M 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions codes apply only to
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following seven boxes. \ certain entities,not individuals;see
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M single-member LLC Exempt payee code(f any)
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❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)►
o Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting
+' w LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is code(if any)
= another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that
0. C) is disregarded from the owner should check the appropriate box for the tax classification of its owner.
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.0 ❑ Other(see instructions)10, (Applies to accounts maintained outside the U.S.)
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6 City,state,and ZIP code
7 List account number(t)here(optional)
Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding.For individuals,this is generally your social security number(SSN).However,for a
resident alien,sole proprietor,or disregarded entity,see the instructions for Pan:I,later.For other
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
TIN, later. or
Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and Employer identification number
Number To Give the Requester for guidelines on whose number to enter. [fli 179
Certification
Under penalties of perjury,1 certify that:
1.The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and
2.1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and
3.1 am a U.S.citizen or other U.S.person(defined below);and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross but item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid,
acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments
other than interest and dividends, ou are not required o sign the certification,but you must provide your correct TIN.See the instructions for Part ll,later.
Sign Signature of
Here U.S.person 10- �i$'f—v(�/5�,__ve Date 0,
General Instructions •Form 1099-DIV(dividends,including those from stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise .Form 1099-MISC(various types of income,prizes,awards,or gross
noted, proceeds)
Future developments.For the latest information about developments .Form 1099-B(stock or mutual fund sales and certain other
related to Form W-9 and its instructions,such as legislation enacted transactions by brokers)
after they were published,go to www.irs.gov/FormW9.
•Form 1099-S(proceeds from real estate transactions)
Purpose of Form •Form 1099-K(merchant card and third party network transactions)
An individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1098-E(student loan interest),
information return with the IRS must obtain your correct taxpayer 1098-T(tuition)
identification number(TIN)which may be your social security number •Form 1099-C(canceled debt)
(SSN),individual taxpayer identification number(ITIN),adoption .Form 1099-A(acquisition or abandonment of secured property)
taxpayer identification number(ATIN),or employer identification number
(EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you are a U.S.person(including a resident
amount reportable on an information return.Examples of information alien),to provide your correct TIN.
returns include,but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might
•Form 1099-INT(interest earned or paid) be subject to backup withholding.See What is backup withholding,
later.
Cat.No.10231X Form W-9(Rev.10-2018)
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Yg Workers! CERTIFICATE OF
s AT Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE
Board
1a. Legal Name&Address of Insured (useGd�,d-�"sC�) 1b. Business Telephone Number of Insured
`Y GD 516-418-2131
NYSS LLC
NY State Solar LLC 1 c. NYS Unemployment Insurance Employer Registration Number of
Suite 11300t St JUL Insured
New York, NY 10001
Work Location of Insured-(Only requi _f rl}very specifi ly li 1d. Federal Employer Identification Number of Insured or Social Security
iced to Number
.,certain locations in New York State, i. 9►
32-0580074
2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) Indemnity Insurance Company of North America
Town of Southold 3b. Policy Number of Entity Listed in Box"fa"
54375 Route 25 C57599236
P.O. Box 1179
Southold, NY 11971 3c. Policy effective period
7/1/2024 to 7/1/2025
3d.The Proprietor, Partners or Executive Officers are
X❑ included.(Only check box if all partners/officers included)
❑ 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 underthe 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 h older and the Wo rkers'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 notamend,
extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities bey o n d 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 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: Kevin Groves
A
rint name of authorized representative or licensed agent of insurance carrier)
Approved by: 06/21/2024
(Signature) (Date)
Title: Vice President
Telephone Number of authorized representative or licensed agent of insurance carrier:469-445-3619
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) 000745 90051004700 7 03 02 0 0000 0 000 www.wcb.ny.gov