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HomeMy WebLinkAbout2013New York State Insurance Fund FYorkers~ Compensation & Disability Benefits Specialists Since 1914 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 Plane: (888) ~97-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 116024590 NORTH FORK ANIMAL WELFARE LEAGUE INC PO BOX 297 SOUTHOLD NY 11971 POLICYHOLDER CERTIFICATE HOLDER NORTH FORK ANIMAL TOWN OF SOUTHOLD WELFARE LEAGUE INC TOWN CLERK PO BOX 297 PO BOX 1179 SOUTHOLD NY 11971 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE Z 673 415-6 628764 08/23/2006 TO 06/01/2014 4/2/2013 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STA'I~ INSURANCE FUND UNDER POUCY NC. 673415-6 UNTIL 06/I)1/2014, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITI-I 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 06/01/2014 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 NOTASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANDCONFERS 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 http$://www, nysif.com/cart/certva .asp or by ce ng (888) 875-5790 VALIDATION NUMBER: 291985507 0/CD48337-21115 STATE OF NEW YORK WORKER~ COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1.To be completed by Disability Benellts Carrier or Licensed Insurance Agent of that Carrier l& L .,,,~1 Name and Addre~ of insured (Uae sire~ address only) NORTH FORK ANIMAL WELFARE LEAGUE INC PO BOX 297 SOUTHOLD, NY 11971 2. Nmlte a~d Addr~s of tl~ Emity requeMJn~ Proof of Co~mage (Entity being lintel ~ the Certlfl~e Holder) TOWN OF SOUTHOLD PO BOX 1179 SOUTHOLD, NY 11971 lb. Business Tdq]hane Numbor of Insured 516-765-1811 1~ NY$ Ummploymmx insurm Employer Regle~Mle~ Number of insured ld. Fader~l Employer Idsmlfl~U0n N~nher of Imurad or SegiM Se~rity Numb~ 116024590 Name of Insurarm~ Carrier The Fir~ RdtabililMIo~ Life ~yof~ ~li~ N~ E ~tl~ I1~ In DBL107~5 01/01/2013 12/31/2013 & [] All of the employer's employees eligible ruder the New YMk Disability Benefits b. [] Only the h)llowing;Imorcl;ssesoftheemployeCsamploym~ Under penalty of perjury, I esrtil~f mol I am an authorized represmT~ive or Ileansed ager~ M'the Insurafl~e eerde~ referenced above and that the namad insurad has NYS Disability Benofits insurmm ~veraga ~s de~rlbad above. Teleph~meNumher 516-829-8100 Title Chief ExecutJve Officer PART 2. To be compIMed by NYS Workers Compensation Board (Only ir box "4b" o~ Part I has been checked) State of New York Worker's Compensation Board Telephone Number Title Please No~: Only imurame esrritn Iiesmad to t~ite NYS DJsabll i~y Benefits insurmme policies and NYS Limned Insurance A~ of those insuranm ~a~d ers are aU~lerizecl ~o issue Form DB-12~ 1. Imuran~e Ix~kefl are NOT auOm41zed to issue this form. DB-120.1 (5-86) Additional Instructions for Form DB-I~0.1 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 "la" for disability henef'r~ under the New York State Disability Benefits Law. The insurance cart ier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in Box "2". This ge~ificete is velid ~ one ye~ after this form Is ap~'oved by the insurance cafTior or its lite~'lSed ageilt, or tile polity e~piratidn date listed in Box Pleas~ No~e: Upon The cancellation of The dis~bifit)' b6nefits policy indicated on This Form, if The busines~ continues ~o be named on a permit, license (x COd~ract issued by a cerTifi c~te holder, The b~siness rnus~ provide That certificate hold~ with a new Cenifi c~e oT NYS Disabilibj, Benefits Coue~age (w other authorized p~oer *.hat The busine~ is compl~ing with The mandating' coverage requirements of The New ¥o~k Sham Disability Benefits Law. DISABILITY BENEFITS LAW Section 220. Subd. 8 (a) The head of 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 notwithstanding any general or special statute requiring or authorizing the issue of such permit, s, 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 for all employees has been secured as provided by this article. Nothing heroin, 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 ir so employed. (b) The head of 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 hy an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefit5 for all employees has been sacumd as provided by this article. DB-120.1 (5-06) Reverse Apr 23 13 11:32a North Fork Animal Welfare 631-765-2203 p. 1 0813012012 15:56 GEN12LER & SHITH ASSOCIATES (FA)0717 741 4720 P.002J(]02 ACORD CERTIFICATE OF LIABILITY INSURANCE [ o* .M ,IaE 30 E E ce ~JIIcate helder la lieu ~f such entitlement{s). ~t~ld, ~ 119~1 CERTIFICATE NUMBER: T~w~ Of~ .q~fle&held REVISION NU THIS 1S TO CERTIFY THAT THE POLICIU-S OF INSURANCE LISTED BELOW NAVE BEEN 1SSUEO TO THE INSURED ~t~,tED AaOVE FOE THE POLICY PER~OO CERTIFICATE HOLDER CANCELLATION ~owm et~ $eutkold Att*. ~rowm Clel~ P.O. Bo~ 1179 So~Cbeld, NY 11971 ACORD 25 (200gl09) Fdrai~ S&erBum/Bl ©tg88-200g ACORD CO~-OR~,TION, All rights reserved, The ACCRD name and logo are registered marks of ACORO