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HomeMy WebLinkAbout2012Lloyd H. Relsenber~, Chairman William G. Young, Vice Chairman David F. Haas Warren W. Jackson Greg Dlckerson February 28, 2012 Southold Town Clerk Ms. E. Neville P O Box 1179 Southold, NY 11971 MATTITUCK FIRE DISTRICT PO BOX 666, PIKE STREET MA'rFITUCK, NEW YORK 11952-0666 John C. Harrison, Secreta~ Barbara Dickemon, Treasurer RECEIVED F£1~ 29 2012 Southola. Town C[,..r~. Dear Ms. Neville, Attached please find the required Certificate of Liability Insurance and supporting schedules for the bond covering our District Treasurer and Deputy District Treasurer. If you require any additional information please do not hesitate to contact me. Sincerely, Harrison Secretary/Fire District Manager Mattituck Fire District cc: Board of Fire Commissioners encl Office (631) 298-8837 Facsimile (631) 298-8841 CERTIFICATE OF LIABILITY INSURANCE I 2/24/2012DATE(MM'DO W' 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 endomement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s~. Lupton & Lace, Inc. IA/cPHONEmo E,,: (631) 727--4114 I rAA/~,NOI: (631)727-7138 225 Howell Avenue [~oaRl~ss:Paula@LuptonandLuce.com INSURER{S~ AEFORDrNG COVERAGE NAJC # Riverhead NY 11901 INSLIRERA'.~.~C~'[ Insurance Group Mattituck Fire District INSURERC: 1000 Pike Street INSURERD: PO Box 666 INSURERE: Mattituck NY 11952 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1222403646 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 ~NDICATED 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 INSR I ~DD[ ISIJBF POLICY EFF POLICY EXP EACH OCCURRENCE $ 1,000,000 X ! COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES {Ea occurrence) $ 100 ~ 000 A I CLAIMS MADE [~ OCCUR ~PK07072606 L2/1/2011 .2/1/2012 BED EXP {Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 x } PO.DY ~ .,~o~ [~ ~oo DeB J J RETENTION $ ['~OH07038206 L2/1/2011 12/1/2012 WORKERS CaM PENSATION I TORY L,MITS I $25,000 Forgory or Altorat±on ¢ovoraga. CERTIFICATE HOLDER CANCELLATION Town of Southold 53095 Main Road Southold, 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 Hallock Lace IV/PAULA ~~_~~ %~ ACORD 25 (2010105) © 1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005) 01 The ACORD name and Iago are registered marks of ACORD POLICY NUMBER: MEPK07072606 CRIME AND FIDELITY CR25 34 10 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADD SCHEDULE EXCESS LIMIT OF INSURANCE FOR SPECIFIED EMPLOYEES OR POSITIONS This endorsement modifies insurance provided under the following: COMMERCIAL CRIME COVERAGE FORM COMMERCIAL CRIME POLICY EMPLOYEE THEFT AND FORGERY POLICY GOVERNMENT CRIME COVERAGE FORM GOVERNMENT CRIME POLICY GOVERNMENT EMPLOYEE THEFT AND FORGERY POLICY and applies to the Employee Theft Insuring Agreement: SCHEDULE Name Schedule Coverage Item Excess Limit Of Insurance No. Names Of Covered "Employees" Each "Employee" $ $ $ Position Schedule Coverage Number Of Excess Limit Of Item Titles Of Locations Of "Employees" Insurance No. Covered Positions Covered Positions Each Position Each "Employee" Deputy Treasurer Mattituck, NY 1 $1,000,000 2 Treasurer Mattituck, NY 1 $1,000,000 $ Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CR 25 34 10 10 © Insurance Services Office, Inc., 2009 Page 1 of 2 POLICY NUMBER: MEPK07072606 CRIME AND FIDELITY CR DS 03 08 07 CRIME AND FIDELITY COVERAGE PART DECLARATIONS (GOVERNMENT ENTITIES) The Crime And Fidelity Coverage Part (Government Entities) consists of this Declarations Form and the Govern- ment Crime Coverage Form. Coverage Is Written: ~ Primary [] Excess ~ Coindem nity r~ Concurrent Limit Of Insurance Deductible Amount Insurin~l A~]reements Per Occurrence Per Occurrence 1. Employee Theft- Per Loss Covera~]e $1,000,000 NA 2. Employee Theft - Per Employee Covera!]e Not Covered N/A 3. For~lery Or Alteration $25,000 NA 4. Inside The Premises - Theft Of Money And Not Covered NA Securities 5. Inside The Premises- Robbery Or Safe Burglary Of Other Property Not Covered 6. Outside The Premises Not Covered NA 7. Computer Fraud Not Covered NA 8. Funds Transfer Fraud Not Covered NA 19. Money Orders And Counterfeit Money Not Covered NA :If "Not Covered" is inserted above opposite any specified Insuring Agreement, such Insuring Agreement and any other reference thereto in this policy is deleted. If Added by Endorsement: Limit Of Insurance Deductible Amount Insurin~l A~]reement(s) Per Occurrence Per Occurrence Employee Theft Schedule See Schedule N/A Endorsements Forming Part Of This Coverage Part When Issued: See attached form GU207 CR DS 03 08 07 © IS© Properties, Inc., 2006 Page 1 of 2