HomeMy WebLinkAboutLiving Wage Certification/Two Defribulator Units
LORl M. HULSE
ASSISTANT TOWN ATTORNEY
lori.montefuBco@town.Bouthold.ny.us
SCOTI' A. RUSSELL
Supervisor
PATRICIA A. FINNEGAN
TOWN ATTORNEY
patricia.finnegan@town.southold.ny.us
KIERAN M. CORCORAN
ASSISTANT TOWN ATTORNEY
kieran.corcoran@town.Bouthold.ny.us
Town Hall Annex, 54375 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1939
Facsimile (631) 765-6639
OFFICE OF THE TOWN ATTORNEY
TOWN OF SOUTHOLD
MEMORANDUM
To:
Ms. Lydia Tortora
From:
Lynne Krauza
Secretary to the Town Attorney
Date:
August 30, 2007
Subject:
Living Wage Certification
AID Grant for HRC for Two Defribulator Units
I am enclosing an original Living Wage Certification form in connection
with the referenced matter. A resolution authorizing Scott to sign this document
will be placed on the Agenda for the September 11, 2007 meeting.
In this regard, kindly have Scott sign and date this form where indicated
and return it to me for handling.
Thank you for your attention. If you have any questions, please do not
hesitate to call me.
Ilk
Enclosure ../'
cc: Ms. Elizabeth A. Neville, Town Clerk (w/encl.) l/""'"
08/29/2007 10:08
,
8523203
LEGISLATOR ROMAINE
PAGE 09
SUFFOLK COlJNTY DEPARTMENT OF LABOR -UrlNG WAGE UNIT
UrING 1YAGECERTIFICATIONffiECLARATlON -SUlIJECTTO AUDIT
H cither of the following dennldons of 'con\pensatlon' (Living Wage Law Chapter 347 _ 2) applies to the contractor'slredplent'.
busine-ss or transaction with Suffolk County, the contractor/recipient mUst complete SecliODS 1,3,4- below; and Form L'V-l
(Notice of Application for County Compensation). If the fonowlng definition. do not apply, the contractor/recll>lent enu.t
coroplete Section. 2,3 and 4 below. Completed fonnl must be submitted to the awarding agency.
.. Any gran~ loan, tax incentive or abatement, bond financing subsidy or other form of compensation of more that $50,000 which is
realized by or provided to an employer ofat least teu (10) employees by or through the authority or approval ofthe County of Suffolk," or
"Any service contracl or .ubcontractlet to n contractor with teo (J 0) or mOre employe.. by the County of SuffQlk far the t\lmishing of
services to or for the County of Suffolk (except contracts where services are incidental 10 the delivery of products, equipmcnt or
commodities) which involve an expenditure equai to or greater than SI 0,000. For the purpose' of this detinition, the amount of
expcnditure for more than. one contract for Ihe .ame service ,haU be aggregated. A contract for the purchase Dr lease of goods, products.
equipment, supplies: or other property is not ~compensation' fot (hI; purposes of this definitiolL"
Secllon I The Living Wage Law applies to thi, contracL ilwe hereby agree to comply with all the provisions of Suffolk County
Local Law No. 12.2001, the Suffolk County Living Wage Law (the Law) and, as such, will provide 10 aU full, part.time
or temporary eroployed pen:ons who perf Otto work or rcnder sCIVices on or for a p(Ojectt matter, corttract OJ subcontract
r-;-l where this company has re<;eived cotnpensation, from the County ofSuffolIc as de1ined in the Law (compensation) a
~ wage rate of no loss than $10.02 (S9.25 for child care providers) per hour workcd with health benefits, as described in
the Law, or othCTWise $11.41 ($10050 for child care providers) per hour or the ralcs as may be adjusted annually in
accordanee with tho Law. (Chopter 347-3 IJ)
Check if
applieabl.
ilwe further agree that any lenant or leaseholder of thi. company that employs alleast tCJ:l (10) persons and occupies
property or uses equipment or property that is Unproved or developed as a result of compensation or allY contractor or
subcontractor of this company that employs at least ten (l0) persons in producing or providing goods or services 10 this
company that are used in the project or matter for which this company has received compensation .hall comply with
all the provisions ufthe Law, including those specified above. (Chapter 347-2)
Section II
Vwe further agree to permil acc... to work sites and relevant payroll records by autborized County representative, for
tho purpose of monitoring complillO.ce with rcguloliollB under this Chapter of lbe Suffolk County Code, investigating
employee complain.. ofnoncomplilll1ce and evaluating tho operation and effects oflhis Chapter, including the
production for inspeclion & copying of payroll records for any or all employees for the term of the contract or for five
(5) years, whichever period of coruplianoc i. longer. All payroll and benefit records required by the County will be
maintained for inspection for a similar period of time. (Chapter 347-7 D)
The County Department of Labor shall review Iha records of any Covered Employer at least once every three years to
verifY compliance with tho provisions ofth. Law. (Chapter 347.... C)
The Living Wage Law does nol apply to this contract for tho follOWing reason(s}:
o
Check if
applicable
Section III
Contractor Name:
Town of Southo1d
Federal Employer \D#:
11-6001939
Contractor Address:
53095 Main Rd. Box 1179
Southo1d, N.Y. 11971
ContractorPbonell: 16311 765-1889 (631) 298-4460
AED Grant - Southo1d Senior Center
De'cription of project or service:
SectioD IV
I declare under penalty of perjwy under the Laws of the State of New York that the underaigned is authorized to prOvide this certification.
and that the above i. true and corrtet
Amount of compensation: $ 2,100.00
Vendor II:
Aulhori~ed Signature
Scott A. Russell, southo1d Town supervisor
P.O.nt Name and Tille:: of Authorized Reprc:seutativc
Date
LW 38 (revised 6'()6. replaces forma LW2, LW3, and LW33)
~~!~~/L~~( l~:~~
tl':JL~LIj~
LEGISLATOR ROMAINE
PAGE 08
SUFFOLK COUNTY DEPARTMENT OF LABOR - LIVING WAGE UNIT
NOTICE OF APPLICATION FOR COUNTY COMPENSATION (Contract)
Living Wage Law, Suffolk County Code, Chapter 347 (2001)
To Be Completed By Applicant! Employer/Contractor
1) NAME:
Southold Town
FED 1D# 11-6001939
2) VENDOR#:
4) CONTACT:
6) ADDRESS:
Town Director of Human Services
750 Pacific street, P.O. Box 85
Mattituck, New York 11952
3) CONTRACT ill #:
(If known)
5) TELEPHONE #: 631 298-4460
(If known)
Karen McLaughlin
7) TERM OF CONTRACT (DATES):
8) PROJECT NAME: (IF DIFFERENT FROM #1)
2007
AF.D - Grant
9) AMOUNT: $ 2,100.00
10) AWARDING AGENCY: Suffolk County Legislator Edward P. Romaine
11) BRIEF DESCRIPTION OF PROJECT OR SERVICE:
Purchase of two AED - Defribulator Units for Southold Town Senior Services Programs
12) PROJECTED EMPLOYMENT NEEDS: (attach a statement listing, by job
classification, the total workforce dedicated to performing th.ls contract or service, including
calculation of estimated net Increase or decrease in jobs as a result of funding).
NA
13) PROJECTED WAGE LEVELS: (attach a statement listing projected wage levels,
compensated days off and medical benefits for total workforce dedicated to fulI"J,lUng tbe terms
of this contract, broken down annually for each year of the term of the contract).
NA
L W, 1 (revised 4/05)
08!2~!2007 10:08
8523203
LEGISLATOR ROHAINE
DATE:
PAGE 02
August 30 ,2007
EXHIBIT B
Community Support Initiative Application Form
Legislative Sponsor:
Edward P. Romaine
Name of Contracting Agency:
Southold Town
THE NAME OF THE CONTRACT AGENCY MUST BE THE SAME AS IT
APPEARS ON THE 501C3 FORM. IN THE EVENT THAT IT DIFFERS, A
LETTER MUST BE ATTACHED EXPLAINING THE INCONSISTENCY.
Federal 10 Number:
11-6001939
Street Address:
53095 Main Road P.O. Box 1179
Southold, NY
11971
Mailing Address (if different):
c/o Southold Senior Services
P.O. Box 85
Mattituck, New York 11952
Scott A. Russell, Town Supervisor
Name and Position:
Daytime Telephone Number:
(631) 765-1889
(631) 298-4460
Ulrec~or OI Human
Services
Grant contact ~erson:
K.aren IVlcLaugn.llIl,
Principal Objective of Agency:
What services do you regularly provide? (Use additional pages as needed)_
southold Town Senior Services is a multi purpose Senior Services program. We provide
a comprehensive array of services to Town residents age 60 and older. (See attached
brochure). Our three main programs include congregate nutrition, home delivered
meals and social model adult day care (see attached).
Purpose of Funding:
Set forth a narrative describing how the program offered by the agency benefits the public and
how the agency will spend the money received from the County. (Use additional pages as
needed)_
The purpose of this funding is to allow for the purchase of 2 defribu1ators (AED Units).
One unit will be stationed in our main dining room and the other will be stationed in
our annex building that houses our adult day care program.
Please complete the attached three (3) page County of Suffolk Program - Budget - Explanation of
Costs form with this application.
08/29/2007 10:08
8523203
LEGISLATOR ROMAINE
PAGE 03
August 30
,2007
Grantee's Nama:
South01d Town
Date:
Budget _ Detail as specifically as possible how this money will be spent and on what it will be
spent Include the following:
Amount
Specify nature of, or type of, item on which
funds will be expended
Personnel:
NA
Equipment:
$ 2,100.00
2 AED Defribulator Units for Townlg ~p.njor
Services Programs
Supplies:
NA
other:
Town portion $723.24
"
"
TOTAL:
$ 2,823.24
*
*
(This price is based on the NYS-OGS
procurement bld 11St)
AED Grant request $ 2,100.00
PLEASE NOTE: All expenditures must demonstrate a public benefit, and be related to the principal objective of the
agency. County funds may not be used for conference attendance, travel. scholarships, partisan political activity,
campaign contributions. holiday parties, religious activities, personal attire. donations to other organizations,
attorney fees, incorporation expenses, or sales tax. THESE USES HAVE BEEN DEEMED IMPERMISSIBLE AND
ARE NOT REIMBURSEABLE.
County funds may be used for the purpose of cardiac defibrillator devices used to protect the public health and
safety, the purchase of football or soccer equlpmenl, the purchase of a set construction for a specific theatre
production to which the public is admitted free of charge or for a nominal fee, a day care program, tile purchase of
furnisl1ings for a homeless program site, aid to run recreational programs, food pantries, commemoration programs
of historical events of County-wide interest. and neighborhood restoration and beautification at public facilities.
In addition, any construction that will assist an organization open to the public in complying with tile Americans with
Oisabilities Act (ADA) would be eligible for County fUnding. As the primary purpose underlying this type of
construction is for the public, with only an incidental benefit running to the organization. such use of County funds Is
acceptable. Therefore, the use of county funds for renovations to widen doorways, construct handicap ramps and
bathroom renovations and to install heightened toilets and railings at such an organization would be acceptable.
The following Items mayor may not be eligible tor County funding depending upon the circumstances. For
example. rent, utilities, and equipment may be permitted. but only where there is a corresponding and proportionate
benefit to the County in the form of programs or services. If an agency is seeking to utilize County funds to pay
50% for Its rent, the agency must establish that its work for the county is at least 50% of its workload. Therefore
rental and utility payments will only be approved to the extent that they are equal to, or less than, the actual vaiLle of
publiC benefit services received by the County. Equipment may only be purchased with County funds if the
equipment will be used to compiete work on a County contract or agreement. This equipment cannot be used for
pllrposes other than in furtherance of the goals of the County contract or agreement. Funding applications for
these types of items identified would require further consuitation between Legislative Counsel and the Presiding
Officer's Office.
Funding applications for items not specifically identified herein will also require consultation between Legislative
Counsel and the Presiding Officer's Office.
A copy of your agency's certificate of Insurance listing the County of Suffolk as an additional insured, and
your agency's Not-Far-Profit Certificate issued by the U.S. Department of Treasury under IRe 501 C3 must
be attached to this application. The contract will not be prepared unless both certificates accompany this
application.
Rev. 4/12107
"2-
08/2q/2007 10:08
8523203
LEGISLATOR ROMAINE
PAGE 04
Grantee's Name:
Southold Town
Date:
August 30 ,2007
Funding Source:
_Omnibus
x
Community Support Initiative
This is only an application form. Your contract will follow under separate cover. The contract
must be fully executed by all parties on or before December 31st of this year.
This form is not a guarantee of reimbursement. Do not incur any expenses specified in the
contract until after it has been signed by all parties. Any and all payments made by the County
cannot be made until there is a legal and fully executed contract. If funds were expended before
the contract was signed, and the agency is seeking reimbursement of those expenditures, the
County must be supplied with agency receipts evidencing payment for the items set forth in the
contract.
Rev. 4/12/07
.3-
08/29/2007 10:08
8523203
LEGISLATOR ROMAINE
PAGE 05
Grantee's Name:
southold Town
Date;
August 3D, 2007
County of Suffolk
Program Budget - Explanation of Costs
1. Personnel Services: Identify what contribution I task I responsibility each staff member
has to the program's operation.
N/A
2. Contracted Services: Identify the type of service each consultant is providing and its
relationship to the program's operation If Administrative costs are included, the
percentage charged as well as the components should be spelled out within that heading.
N/A
Rev. 4/12/07
-4-
08/29/2007 10:08
8523203
LEGISLATOR ROMAINE
PAGE 05
Grantee's Name:
Southold Town
Date:
August3Q'2007
3. Maintenance and Operations:
a. Equipment: Identify if the equipment is new or replacement, and briefly explain its
relevance to ttle program. (See attached description from Cardiac Science Corp.)
We plan to purchase 2 AED Debribulator units for southold Town's Senior Services
Programs. One unit will be available in the main Center which houses our
community and nutrition programs. The other unit will be stationed at our
annex building which houses our Senior Adult Day Care Program.
b. Supplies: Explain the relevance of the supplies to the program.
N/A
c Utilities: Explain how the costs were calculated. Specify and delineate if the costs
are pro-rated on space, occupancy, or a percentage of time allocated to the
program.
N/A
Rev. 4/12107
-5-
~~/4~/~~~t l~:~~
8!o:i3:iU3
LEGISLATOR ROMAINE
PAGE 137
.
Grantee's Name:
Southold Town
Date:
Aug. 30 , 2007
4. Facilitv Repairs / Additional Costs
a. Additional Costs: EOxplain the relevance and/or need of these items to the
program.
N/A
b. ~acility Repairs: Explain the repairs and show how they are for general upkeep
and not for capital replacement.
N/A
Rev. 4/12/07
-6-
. .N.\.}' coNfr"(~,CT:H- ?C-58T7{P
08/29/200~ 09:44 IFAX 3rdfloorfax@cardiacsc1encc.com
C-Af:'DIAC. :)c.-Ienc<d. CC5Yp
., Lisa Huffman IiiI 002/003
~. '"
CARDIAC SCIENCE
'--.y
POWERJHEARr
PURCHASE AGREEMENT
Sales Rep:
Lisa Huffman PH62
Date:
August 29. 2007
ttlJ.."t(']llJl::I:I:II..I~[d1MI:[.l:h'.r.,.[.l~
Company: Southold Town Human Resource Center
Address 1: 750 Pacific Street
Address 2: Po Box 85
City: Mattituck
State: NY Zip: 11952
COUNTY:
Contact Name:
Title:
Phone:
Fax:
Ms. JaCQueline Martinez
631.298-4460
631-298-4462
E-mail: iacouellnemartineztmtown.SOuthold.nv.us
Email Restrtction: Restriction Type:
Invoice to: @ COq:JoI'Ml: Billing Mdrl:$$
Payment Term: Payment due upon receipt
Payment: Check
Mrkl Segment Government - State/local
o 1~,~~.~~.(,~.~llsl__ J.!"-x eKemption tI To Follow
:s~Iy.e~y~~!!tT~[J!l.~__Il~!!jr Q!!l~f "t P.O. tI To Follow
Lead Source: Call1r'lf CUlTonl Cu.tomer- Misc.
ti'}"'1II.l\lJI:I:"''1:II:.1:.1I~IC'llml..ml'l,,'n.h'
ClasllD: End User
Company:
Address 1:
Address 2:
City:
State:
COUNTY:
F.Q.B.:
Southold Town Human Resource Center
750 Pacific Streel
Po Box 85
Mattituck
NY Zip: 11952
Contact Name:
Tille:
Phone:
Fax:
E-mail:
Shipping Method:
Freight Collect Account:
Ms. Jacouellne Martinez
631-296-4<160
631-298-<4462
laooueline.martlnez@town.southold.nv.us
FedEx - GROUND
powerheart AEO G3 Plus AHA.ali ned Automatic Packa
AED
9390A-501 P
2 495.00
$
1 346.62
U r.deO lion
Adult Defibrillation Pads - two- ear shelf life
Read Kit for 9300 series AEO G3: indudes nitrile loves
Ca in case for 9300 series AED G3
AEO Accessories
AEO Accessories
AED Accessories
9131-001
5550-003
168-e00o-001
43.95
59.95
99.95
18D-2022-001
65.00
u.lln. Martinez
Ilne.ma In z W
Res onse Pro ram Mana ement
Res onse Pro ram Mana ement
RPM Accessories
RPM Accessories
RPM Accessories
RPM Accessories
Miscellaneous field
COMMENTS/CONTRACT NOTES: ....Quote Explr.. In 60 Day. ....
This quote is per the NY state contract PGB-00549.
$
$
$
$
$
$
$
$
$
$
$
$
Subtotal: $ 1,411.62
Sales Tax:
Shl In : NA
TOTAL
1411.62
BY SJGHING THJS AGREEMENT, CUSTOMER REPRESENTS THA T THEY ARE AUTHORIZED TO PURCHASE AND AGREES TO CARDIAC SCfENCE TERMS" CONDlnONS.
AED Innd for rn rf h I
Aulho1fz~d S/gn~ture: Print N.",.: TdJo D~":
for PAYMENTS Mall to:
Cardiac Selene. CorporaUon
Dept. 0587
PO Box 120587
Dallas, TX 75312-0587
FAX TO:
FAX TO:
425-402-2064 Cardiac Seloneo Ordor Entry
Sales Representative
~>l~_~_
_''''1
YNMI cardlacaclence com
E-mBil: cUSlomerS~l\IiceOcardlacacJence.com
Nlld.q: CSCX
Cardiac Sclenee corporation
3303 Monte Villa Parkway
Bothell, WA 98021
Tel: +1.800.991.6465
R~g 29 2007 11:~~nl'
.
~o~ H ~eeve Hgenc~.
0312983850
e._1__._
ACORD CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDDIYYYY)
n< 08/29/2007
PRODUCEll. Phooe (631) ;?98-47OO F;oc 63'-296-3~50 THIS CERTIACATE IS ISSUED AS A MATTER 0: INFORMA.TION
ROY H REEVE AGENCY. INC. ONLY AND CONFERS NO RIGHTS UPON THE C ERllACATE
PO ElOX 54 HOLD ER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
MATTITUCK NY 11952 At. TER THE COVERAGE AFFORDED BY THE POlICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC#
- ._",- -- ------ u - - ---,.
INSURED INSURERA: MARKEL AMERICAN INS CO ._.~ 2~.9.~__
TOWN OF SOUTHOLD INSURER B: --
C/O SOUTH OLD TOWN HALL INSURER C;
P.O. BOX 1179 , .__u. ...---
SOUTH OLD NY 11971 INsuRER 0: ,
.------- - -.- ---- ,
INSURER E: i
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLley PERIOD INDICI\TEO, NOTWll ;STANOING
ANY REOUIRUAEJJT, TERM OR CONDITION OF ~Y CONrRACT DR OTHER DOCUMENT WrrH RESPECT TO WHICH THIS CERTIFICATE tMy BE ISSU:O OR
MAY PERTAIN, THE INsuRANCE AfFORDEo BY THE I'OllCIES DESCRIBED IlEREIN IS SUBJECT TO ALL THE TERMS, EXCLUStoNS AND CONDITIONS OF SUCH
POLICIES, AGGREGATE lIMllS SHOWN MAY HAVE BEEN REDUCED BY PAID CLo'JMS. .._--
. .- ---.-----
I~~:II~~ TYPE OF INS URANCE POLICY NUMBER P~~~~~~~E ~~~.~":=N UMTS
! ~NERA.llIABIUrY CPEL-1001-07 01/01/07 01101/08 EACH OCCURRENCE I' 1,000..0QQ.
X COMMERCIAL GENERAL LIABILITY DfoJMGE TO REtlTED . N/A
- --=-l- CLAIMS MADE ~ OCCUR PRE"'.SES(E.IIlI:o<:unlOOI)
, MED. EXP (Any 011. per:ton) !-_--_._-~--~!~
I .-
A i X $50,000. DEDUCT1BlE(SIR) PERSONAL & MJV INJURY _ _ ' 1.00~~
, -
I OENERAlAGGREGATE , 3,0.0",000
GEN'l AGGREGAliU~IlT APPLIES PER~ I ~----.---
PRODUCTS-COtv'P/OP AGG , 1.000,000
I ~n PRO. n I .._.-..-
POLlCY JECT LOG I
, AUTOMOSlLE WASlllTV COMBINED SINGLE LIMIT
, -'-=,- I (Eaacoldenl, ,
--1 ~1.fY AUTO ..__..0
; All OVINEO AUTOS ElODlL Y 11\1JURY
i -' (Perpenoon) ,
SCHEDUI EVA-UTOS
-- . --
- HIRED AUTOS SODILY It-lJURY
NON-OWNED AurOS (PPJracc;:ldMt) ,
- .. -. .--- ._'u.u_.
- . .....---- -.- PROPERTY1~AMAGE ,
(Pereocldenl
GARAGE LIABILITY AUTO ONLY. EA AG.<;:IDEN] ,
==i ANY AUTO OnlE.R THAN EAA;C I,
-~_._~_..~ .._~.
AUTO ONLY: A-,G ,
EXCESS I UMBREt..LA. UABlllTY EACH OCCURRENCE ,
0- OCCUR 0 ClAIMS MADE AGGREGATE .
--
,
..- ~~-----
~-==t DEDUCTIBLE. ,
---_..---
I RETENTKJN :J ,
WORI(ERS COMPENSATION AND IWCSTATUo,l 101>,.
TORVlU.llTS ----.-- .
EMPLOYERS' LIABILITY .~
EL EACH ACCIOE NT .
AN'( PROPRla;TORJPARTIoERlEXECUTlVE --.-
OFFICERlMEMOEA EXCLUDED? E.L. OISEAS E-EA EMPLOYE : ~--,.._~_..-
--
lIy.~, lJ..~c'l"" urNIOI E.l. [)ISEASE~POLICY LIMIT .
SPECIAL PROVl810MJ ~I-
OTHER:
\ .
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIO is
CERTIFICATE HO~DER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CAN ~LlED BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL Et OEAVOR TO MAlL 10 DAYS
WRnlEN NOTICE TO THE CERTIFICATE HOLDER ~D TO THE lEFT, BUT fAILURE
COUNTY OF SUFFOLK TO DO SO SHAU IMPOSE NO OBUGATlON OR UABILllY OF At<< -(INO UPON THE INSlIRtoR.
P.O. BOX 6100 ITS AGENTS OR REPRESENTATIVES.
HAUPPAUGE, NY 11188 AUTHORIZED REPRESENTATIVE ~~
Attention:
..
ACORD 25 (2001/08)
Certificate #
10248
@ACORD(ORPORATION 198B
.Rug 29 2007 11:23AM Ra~ H Reeve Agenc~
.
6312983850
-_._--~--
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A sta :ement
on this cert~icate 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 polici ~s may
require an endorsement. A statement on this certificate does not confer rights to the certiflcat"
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on lI1e reverse side of this form does not constitute a contract be~ veen
the issuing insurer(sl, authorized representative or producer, and the certificate holder, nor do"s it
affirmatively or negativeiy amend, extend or alter the coverage afforded by lI1e policies listed thereon.
ACORD 25-8 (200 1/08)
Certificate 1110248