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HomeMy WebLinkAbout2011RECEIVED JUN 9 2011 New York State Insurance Fund Workers' Compensation & DisabiliO~ Benefits Specialists Since 1914 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 Phone: (888) 997-3~63 ~oulhold Town Cled~ CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^"^ ^^ ^ 116024590 NORTH FORK ANIMAL WELFARE LEAGUE INC PO BOX 297 SOUTHOLD NY 11971 POLICYHOLDER NORTH FORK ANIMAL WELFARE LEAGUE INC PO BOX 297 SOUTHOLD NY 11971 CERTIFICATE HOLDER TOWN OF SOUTHOLD TOWN HALL MAIN ST SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER Z 673415~ 257023 PERIOD COVERED BYTHIS CERTIFICATE DATE 08/23/2004 TO 06/01/2013 5/3/2011 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE iS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 673415-6 UNTIL 06/01/2013, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 06/01/2013 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER'ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIONONLYANDCONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. U 26,3 NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https:llwww.nysif, comlcertlcertvaLasp or by calling (886) 875-5790 VALIDATION NUMBER: 845985708 0/CD36808-21/13 ACORE, CERTIFICATE OF LIABILITY INSUR I EArs,MM,DU,,,YY,06/Z0/Z011 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 BETWEEI~.E I~jSBINL~0~SURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A state~tent~on.t~l~ certificate, does not confer rights to the certificate holder in lieu of such endorsement(s}. ;~0u.t0la 10WA CONTACT PRODUCER I NAME: Prince Associates, Tnc. RHONE i~uc, .o, E.,~: (516)822-6550 __ ] [~A[c, Nol~ _( 5_ 16_)_8_~._2 ~- 6564 183 Broadway E-MA~L ADDRESS: Hicksville, NY 11801 PRODUCER CUSTOMER ~D #: INSURER(S) AFFORDING COVERAGE NAIC # Northfork Animal t~elfare League Inc PO Box 297 INSURERC: Southhold, NY 11971 'INSURERU; INSURER E; INSURER F: COVERAGES CERTIFICATE NUMBER: TwA of $outhold 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 ANU CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. GENERAL LIABILITY lZSBARK54Z; 07101/2011 07101/2012 EACHOCCURRENCE $ 1,000,000 ! i X / COMMERCIAL GENERAL LIABILITY · ~ PREMISES lea occ,~rrenc~l $ 1,000,000 I [xj A ' PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ Z, 000,000 I $ , i:UMBRELLALIAS I x/p0cuR 12SBARK5421 0710112011 07101/2012 ._EA_C~HOCCURRENCE S 1,000,000 A ,L ~XCESi~ ...... ] ~LAIMS MADE AGGREGATE ...... X ~ re'EAt"ON ~ 10,000 WORKERS COMPENSATION I TORY LIMITS I Certificate Holder as Landlord of premises (269 Peconic Land, Peconic, NY) is Additional Insured. CERTIFICATE HOLDER CANCELLATION Town of Southold Att: Town Clerk P.O. Box 1179 So~thold, NY 11971 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Linda Godnick © f988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD DATE IMM/DD/YYYY) A(JU/ M CERTIFICATE OF LIABILITY INSURANCE o6/20/2011 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 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). CONTACT PRODUCER NAME: iA]Ct NorExt): (516)822-6550 I ~C, No): (516)822-6564 183 Broadway E-MA~L Hicksville, NY 11801 PRODUCER Northfork Animal Welfare League Inc INSURERB: PO Box 297 INSURERC: Southhold, NY 11971 INSURERD: COVERAGES CERTIFICATE NUMBER: Twn of $outhold 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, ADDI ISUBR POLICY EFF POLICY EXP IN~R TYPE OF INSURANCE INSR WV{3 POLICY NUMBER MM/DDPC~i~yi iMMiDD/Yyyyi LIMITS LTR GENERAL LIABILITY 12SBARK5422 07/01/20il 07/01/20t2 EACH OCCURRENCE $ 1,000,00( DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES/Ea cccurrencel $ 1,000,00( I CLAIMS-MADE [] OCCUR MED EXP (Any one person} $ 10,00( A PERSONAL & ADV INJURY $ 1,000 ~ 00( -- GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ ? ~ 000 ~ 00( PRO AUTOMOBILE LIABILITY COMBi'NED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person} ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) NON-OWNED AUTOS UMBRELLALIAB Xl OCCUR 12SBARK5422 07/0~/2011 07/0~/2012 EACH OCCURRENCE $ 1,000,00( [XCESS LIAB~ ~ CLAIMS-MADE AGGREGATE $ 1,000,00( A DEDUCTIBLE X i RETENTION $ 10,00( $ WC STATU- WORKERS COMPENSATION I TORY LIMITS I IO~lRM- AND EMPLOYERS' LIABILITY Y ! N I ANY PROPRIETOPJPARTNER EXECUTIVE EL EACH ACCIDENT $ I OFFICER/MEMBER EXCLUDED? N I A i (Mandatoryln NH) EL DISEASE - EAEMPLOYEE $ if yes describe under EL DISEASE - POLICY LIMIT i DESCRIPTION OF OPERAT ONS be ow DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (A[tach ACORD 101, Additional Remarks Schedule, if more space is requi~ed) :ertificate Holder as Landlord of prern-ises (269 Peconic Land, Peconic, NY) is Additional Tnsured. CERTIFICATE HOLDER CANCELLATION Town of Southold Att: Town Clerk P.O. Box 1179 So~thold, NY 11971 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Linda Godnick © 1988-2009 ACORD CORPORATION. All rights reserved; ACORD 25 (2009~09) The ACORD name and logo are registered marks of ACORD New York State Insurance Fund Workers' Compensation & DisabiliO; Benefits Specialists Since 1914 199 CHURCH STREET. ~IEW YORK N.Y. 10007-1100 Phone: .~88) 997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 116024590 NORTH FORK ANIMAL WELFARE LEAGUE PO BOX 297 SOUTHOLD k!Y 1'i971 POLICYHOLDER NORTH FORK ANIMAL WELFARE LEAGUE INC PO BOX 297 SOUTHOLD NY 1 CERTIFICATE HOLDER TOWN OF SOUTHOLD TOWN HALL MAIN ST SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE Z 673 415~ 257023 08/2312004 TO 06/01/2013 5/3/2011 THIS S TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE S INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO 673415-6 UNTIL 06/01/2013. COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE ~EW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK. EXCEPT AS iNDICATED BELOW. AND. WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK. TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. c SAID POLICY IS CANCELLED. OR CHANGED PRIOR TO06/01/2013 IN SUCF MANNER AS TO AFFECT THIS CERTIFICATE. 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS 'PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANYLIABILITYIN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE S ISSUED AS A MATTER OF NFORMATIONONLYAND CONFERS NO RIGHTS NOR iNSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY U-26.3 NEW YORK STATE INSURANCE FUND DIRECTOR ~NSURANCE FUND UNDERWRITING This certificate can be validated on ourweb site at https://www, nysif, com/ceCdcedval.asg or by calling (888) 975-5790 VALIDATION NUMBER: 845985708 0/CD36808-21/13 STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DIS~BIUI'Y GENEF~S PART 1 .To be completed by Disability Benefits Can-ier or UcenseCl InsuraiTce .~gent l& Legal Name and Address of Insu~d (Use ss~set address only) lb. NORTH FORK ANIMAL WELFARE LEAGUE INC PO BOX 297 SOUTHOLD, NY 11971 2. Name and Address of tha Entity requastlng Proof of Coverage (Entlt~ being listed as the Ceslifleate Holder) Town of Southold PO Box 1179 Southold, NY 11971 4. Policy covers: a. ~'} All of the emltloye~'e employees eligible under the New York Oisal~tli~,aet~Tlts ~w b, [] Only tJ~ followlngelassorolassesof~he~mplo~r's~mpl~jee~: a~ and ~ ~ ~med I~d has NYS Dl~blll~ ~flu I~~~ Da~ Slgn~ 1/17~012 By TeI~O Num~ 516-829-8100 Tm, ~M ~e~e ~i~ ......., ......... PART 2. To be completed by NYS WorkeCs Com~saa~ State of N~ Worker's Compensa~ Board Date Signed By Telephone Number Title Please Not~: Only Insurance carriers licensed to write NYS Dlsablll~ OelselTts insurance ~hase ths~room c~rrlers are sutherlzed to issue Form DB-I~O.1, Insuranto bmkeis~ NOT DD-120.1 (5-06) Additional Instructions for Form DB-120.1 By signing this form, the insurance carrier identified in Box'3' on this form iscerUfl~ir~ business referenced in Box '1 a' for disebility benefits under the New York State Oisab~f-~,~13~,its ~aw. The imureflce carrier or its licensed agent will send this Certificate oF Insurance to the enti~y ~[iste~ ~as ~he ~:er~fflOate holder in Box "2'. This certificate is velld for ttm ~rlier ar o~le ]/ear alter this form ~s q~prove~ ~b~ ~tta itl~ui'an'se oerrier or its l ise~sed agent, or the polloy expiration date Ilste~ in Box Please Note: Upon [he cancellation of [he disability beneats policy indtcetecl on this form, ff ~e ~m~siness ~.on~iA u~s:t o ~Ue ,n~m ed on a permit, license ar con~'act issued by a certificate hold~, the business mu~ ~rovl0e ~tat ~Jcate =hol~er ~viU1 ~c~le~v Certificate of N¥$ DisebJltty Benefits Coverage or other eutherized proofb'lat the busi~ Js ~J~mP ¥ rig ~,Oil~ ~ h~ ~r~er ~tt ¢~y coverage requirern~lts of [Ise New York State Oisebility Benefits I.aw. DISABILITY BENEFITS LA~ Section 220. Subd. 8 (a) The heed o1' state or municipal department, board, commission or ol~ice authorized ~r ~eq~ir~l law to Issue any permit for or in connection with any work involving the emptoyr~ent ~of ~lOy~s employment as defined in this article, and no[withstanding any general Or s~ec~l authorizing the issue of such permits, shall not issue such permit unless proof du}y ~ube~lbel~ insurance carrier is produced in a form satisfactory to the chair, that the payment o~is~ii~. for all employees has been secured as provided by this arUcle. Nothing herein. ~howe~e~. ~ll construed as creating any liability on the part oi" such state or municipal deparal~Rt~ ~ard, or office to pay any disability benefits to any such employee il"so employed. (b) The head of state or municipal department, board, commission, or ot'~=e e~h~z~l =r law to enter into any contract for or in connection with any work t~vol~t~Ig ~1'~ ~mi~to~,me~t re~ ~er~-i~lo. in employment as defined in this article, and notwithstanding any genera1 or special authorizing any such contract, shall not enter into any such ~:antract unless ~oi'~l[Ji~ ~u~ibed insurance carrier is procluced in a form satisfactory totha chair, that the all employees has been secured as provided by this article. DB-120.1 (5.06) Reverse