HomeMy WebLinkAboutInsurance Program Proposals y+► . . gfrt4 r.
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Town Hall, 53095 Main Road
P.O. Box 1179
�� Southold, New York 11971
JUDITH T. TERRY TELEPHONE
TOWN CLERK: (516) 765-1801
RecisrR.AR OE VIT srnTisruCs OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION WAS ADOPTED BY THE
SOUTHOLD TOWN BOARD AT A REGULAR MEETING HELD ON DECEMBER 1, 1987:
RESOLVED that the Town Board of the Town of Southold hereby authorizes
the firm of Griffing & Southwick, Inc. , 55 North Ferry Road, Shelter Island,
New York, to act as the Town's insurance producer effective January 1, 1988.
J udith T. Terry
Southold Town Cler
December 2, 1987
Griffing&Southwick,Inc.
55 North Ferry Road
Shelter Island,NY 11964
(516)749-0484
November 30 , 1987
Town of Southold
53095 Main Road
PO Box 1179
Southold, NY 11971
ATT : Judy Terry , Town Clerk
RE : Insurance quote by specifications offered September 1987
We are pleased to have the opportunity to quote on the insurance
needs for the Town of Southold . Our proposal of premium quotes
is enclosed .
We offer the insurance quotes and proposals subject to some
conditions-
The
onditions_.The auto quote is offered based on the assumption that the drivers
of Town vehicles are acceptable drivers . We have enclosed a form
that outlines an unacceptable driver . We must advise you of this
condition since we did not have the benefit of a driver list . We
have corrected a number of vehicle classification errors that were
found in your current policy .
The Liability quote is for a Claims Made policy . Your prior coverage
has been written on an occurrence form. Your Insurance Consultant ,
Mr . William Mullen Jr . , can outline the differences for you. The
new liability format , just approved in the State of New Your ,
eliminates the liability coverages for the Police Department so
that it would be necessary to have Law Enforcement liability and
make certain that the Law Enforcement policy include the premises
(OL & T) liability .
The Cigna Insurance Company would require that there be a Prior
Notice Law in effect prior to a CIGNA policy being in effect on
January 1 , 1988 .
Our bid omits the Law Enforcement Liability and Public Officials
liability due to the fact that the incumbent carriers most likely
provide the best coverage at the best price .
Agents for Insurance Company of North America, Aetna Insurance Company and Bankers Standard Insurance Company, CIGNA companies
HH?H20
Griffing&Southwick,Inc.
55 North Ferry Road
Shelter Island,NY 11964
(516)749-0484
We are certain that we can work with the Town of Southold on any
recommendations on specifications for the Company . We look forward
to providing insurance service to the Town of Southold . Our staff
is trained in the Municipal insurance needs with our background
in providing coverage for the Town of Shelter Island and the Town
of Riverhead .
Very Truly Yours ,
?11/1iam�AS a u tih w�ic k
WCS/tmt
Encl :
Agents for Insurance Company of North America, Aetna Insurance Company and Bankers Standard Insurance Company, CIGNA companies
HH IH20
30
P R E M I U M Q U O T A T I O N
(To be submitted in duplicate)
A. Buiding and Contents
Deductible All':Bisk Annual Cost
$1;000 YES $26 , 500 .00
Carrier: CIGNA Insurance Companies
Policy Period: 01 /01 /88 to 01 /01 /84
Premium Payment Plan: Installments available
Comments: Section I Pakkage includes Extra Expense. ' Boiler &
Machinery; Valuable Papers , Employees Blanket Bond
B. Extra Expense
Deductible All Risk Annual Cost
$1, 000
Carrier:
Policy Period:
Premium Payment Plan:
Comments: Included as per specifications , in Section I Package
C. Boiler and Machinery
Deductible
$5,000
Carrier:
Policy Period:
Premium Payment Plan:
Comments: Included in Section T Package
310
D. •Valuable Papers
Deductible
$1,000
Carrier:
Policy Period:
Premium Payment Plan:
Comments: Included in Section I of Package
$500 , 000 . Premium $82 ,000 .
E. Comprehensive General Liability$ 1 ,000 ,000. Premium $96 ,000.
(a) First dollar coverage: $500, 000 or $1,000, 000
Rating basis: Based on adjusted Budget of $6 , 127 ,000 .
Carrier: CIGNA Insurance Companies
Premium Payment Plan: Installments
Comments: Claims Made - no coverage for Police under the new New York
form. Require Police Professional policy to cover Police OL 6 T .
$500,000. Premium $95 ,000 .
F. Automobile Insurance $ 1 ,000,000 . Premium $ 113 ,000.
Limits - (a) $500, 000 or $1,000 , 000
Rate per vehicle: Claims History - 16% debit
Carrier: CIGNA Insurance Companies
Policy Period: 01 /01 /88 to 01 /01 /89
Premium Payment Plan: Installments available
G. Contractors Equipment Floater
Deductible Rate per 100 Exposure
Varies from specific to unscheduled
$1,000 Premium $ 14 , 618 . Average $ 1 .08
Carrier: CIGNA Insurance Companies
Policy Period: 01/01/88 to, 01 /01 /89
Premium Payment Plan: Annual Payment
Comments:
H. Umbrella Liablity
$1,000,000 - $2, 000, 000 - $3, 000,000 - $4,000,000 - $5,000,000
Rating basis:
Carrier:
Policy Period:
Premium Payment Plan:
Comments: Quotes - if .any will come from CIGNA Companies - not
yet available .
I. Police Professional Liability
Premuim: Renewal as ver National Union Insurance Comuanv
Carrier: National Union
Policy. Period: 01 /01 /88 to 01 /01/89
Comments: Alternative quote - City Insurance Co . with $500,000 .
limits - not vet available .
J. Public Employee Blanket Bond and Crime
Premium:
Carrier:
Policy Period:
Comments: Included as per specifications in Section I of package .
30
. PREMIUM QUOTATION SUMMARY
Total annual-:cost of all coverages with deductibles;
the property coverage including Boiler and Machinery.
INCLUDES :
A,B,C ,D ,E ,F , $1,000 Deductible: $ 1 ,000 ,000 . Liability - $250, 118 .
G & J
$5, 000 Deductible: Reduction in premium not significant
$ 1 ,000 . Deductible : $500 ,000 . Liability - $218 , 118 .
Griffin& & Sout'hwicl, Inc .
Name of Agent/Broker
55 North Ferry Road
Street or P.O. Box
Shelter Island, NY 11964
City, State, and Zip
William C . Southwick
ame of Per Comp eting Quotation
Signatur .
Title
Date: November 30, 1987
Public Officials Liability would be renewed with Tudor Insurance Co .
UNACCEPTABLE DRIVER
Any driver who in the past three years:
(1) Has been involved in three or more accidents (regardless
of fault.
(2) Been convicted of any of the following violations.
(A) Driving while intoxicated.
(B) Driving under the influence of drugs.
(C) Negligent homicide arising out of the use of a
motor vehicle (gross negligence).
(D) Operating during a period of suspension or
revocation.
(E) Using a motor vehicle for the commission of a
felony.
(F) Aggravated assault with a motor vehicle.
(G) Operating a motor vehicle without owner's authority
(grand theft).
(H) Permitting an unlicensed person to drive.
(I) Reckless driving.
(J) Speed contest.
(K) Hit and run (BI and PD) driving.
(3) Any combination of violations not listed and/or accidents in
the past three (3) years that equals four (4) or more.
e
UNACCEPTABLE DRIVER
Any driver who in the past three years:
(1) Has been involved in three or more accidents (regardless
of fault.
(2) Been convicted of any of the following violations.
(A) Driving while intoxicated.
(B) Driving under the influence of drugs.
(C) Negligent homicide arising out of the use of a
motor vehicle (gross negligence).
(D) Operating during a period of suspension or
revocation.
(E) Using a motor vehicle for the commission of a
felony.
(F) Aggravated assault with a motor vehicle.
(G) Operating a motor vehicle without owner's authority
(grand theft).
(H) Permitting an unlicensed person to drive.
(I) Reckless driving.
(J) Speed contest.
(K) Hit and run (BI and PD) driving.
(3) Any combination of violations not listed and/or accidents in
the past three (3) years that equals four (4) or more.
/Cory peeve A9ency, inc.
MAIN ROAD
MATTITUCK, NEW YORK, 11952
298-4700 722-3520
TODAY'S LOSS IS NOT PAID BY TOMORROW'S INSURANCE
NOVEMBER 25, 1987
JUDITH T. TERRY, TOWN CLERK,
TOWN OF SOUTHOLD,
53095 MAIM ROAD,
SOUTHOLD, ..N.Y. 11971
RE: INSURANCE PROPOSAL
DEAR JUDY,
ATTACHED HERETO IS OUR BID, IN DUPLICATE, FOR THE
COMMERCIAL AUTOMOBILE POLICY AND THE CONTRACTOR'S EQUIPMENT
POLICY, IN ACCORDANCE WITH THE INSURANCE SPECIFICATIONS OF
SEPTEMBER, 1987.
PLEASE NOTE THAT WE HAVE QUOTED 81 VEHICLES IN THE AUTO
SCHEDULE, RATHER THAN THE 79 LISTED IN THE SPECS. 'TWO ITEMS,
MOBIL SWEEPERS, ARE INCLUDED BECUASE OF A REDEFINITION OF MOBILE
EQUIPMENT IN THE COMPREHENSIVE GENERAL LIABILITY "SIMPLIFIED„
POLICY. OUR PROPOSAL IS FOR $1,000,000. COMBINED SINGLE LIMIT
LIABILITY, $50,000. PERSONAL INJURY PROTECTION AND $20,000.
UNINSURED MOTORIST COVERAGE, ON AN "ANY AUTO" BASIS. EMPLOYERS
NON-OWNERSHIP AUTO LIABILITY AND HIRED CAR COVERAGE ARE ALSO
INCLUDED. PHYSICAL DAMAGE COVERAGE ($500. DEDUCTIBLE
COMPREHENSIVE AND COLLISION) IS INCLUDED FOR 47 VEHICLES OF THE
FLEET.
CONTRACTORS EQUIPMENT FLOATER IS QUOTED AS PER
SPECIFICATIONS, EXCEPT THAT LIABILITY COVERAGE FOR EQUIPMENT IS
NOT PROVIDED UNDER THE EQUIPMENT FLOATER. ANY NEEDED LIABILITY
THAT IS NOT PROVIDED AUTOMATICALLY BY THE COMPREHENSIVE GENERAL
LIABILITY POLICY IS AUTOMATICALLY PROVIDED BY THE "ANY AUTO"
COVERAGE OF THE AUTOMOBILE POLICY.
SHOULD THERE BE ANY QUESTIONS ON ANY OF THESE ITEMS, WE
WOULD BE PLEASE TO DISCUSS THEM AT THE CONVENIENCE OF THE TOWN.
WE WISH TO EXPRESS OUR APPRECIATION FOR THE OPPORTUNITY
TO PROVIDE THIS QUOTATION.
VER TRULY YO S,
a
IAy//
rNT
t' •
30
P R E M I U M Q U O T A T I O N
(To be submitted in duplicate)
A. Buiding and Contents
Deductible All':Risk Annual Cost
$1;000
Carrier: NO BID
Policy Period:
Premium Payment Plan:
Comments :
B. Extra Expense
Deductible All Risk Annual Cost
$1, 000
Carrier: NO BID
Policy Period:
Premium Payment Plan:
Comments:
C. Boiler and Machinery
Deductible
$5 , 000
Carrier: NO BID
Policy Period:
Premium Payment Plan:
Comments :
. r
.. •31
1 •.
D. -Valuable Papers
Deductible
$1, 000
Carrier: NO BID
Policy Period:
Premium Payment Plan:
Comments:
E. Comprehensive General Liability
(a) First dollar coverage: $500, 000 or $1, 000 , 000
Rating basis:
Carrier: NO RTD
Premium Payment Plan:
Comments:
F. Automobile Insurance
Limits - (a) $500, 000 or $1, 000 , 000
Rate per vehicle: Average - $1459.88 Total Premium - $118,647.
Carrier:, Hartford Insurance Group
Policy Period: 1-1-88 / 1-1-89
Premium Payment Plan: 20% Down pay - 8 months at 10%
G. Contractors Equipment Floater
Deductible Rate per 100 Exposure
$1, 000 1.00
Carrier: Hartford Insurance Group
Policy Period: 1-1-88 / 1-1-89
.y' 032
Premium Payment Plan: 100% at inception
Comments:
H. Umbrella Liablity
$1, 000, 000 - $2, 000 , 000 - $3 , 000 , 000 - $4, 000 , 000 - $5 , 000 , 000
Rating basis:
Carrier: • NO BID
Policy Period:
Premium Payment Plan:
Comments:
I. Police Professional Liability
Premuim:
Carrier: NO BID
Policy Period:
Comments:
J. Public Employee Blanket Bond and Crime
Premium:
Carrier: NO BID
Policy Period:
Comments:
f, 034
PREMIUM
34
PREMIUM QUOTATION SUMMARY
COMMERCIAL AUTO POLICY - $118,647.
Total annual :cost of
CONTRACT'OR'S EQUIPMENT FLOATER WITH
$1, 000 Deductible: $1580.
TOTAL COST - $120,227.
a
Rov H Reeve Agency Inc.
Name of Agent/Broker
Main Road, P 0 Box 54
Street or P.O. Box
Mattituck, New York 11952
City, State, and Zip
R)etjprt J. Mc Carthy
ame f Person Completing Quotatior
S I gtA ur
_ Vi eP Praci dpn
Title
Date:
SEP 2 5 W
TOWN OF SOUTHOLD TO"
PRE-QUALik-ICATION
• Da to : SeptCELg 24 1987
Name of Firm: A.C. Edwards, Inc,
Servicing Office Address 48 Main Street
Sayville, NY .
Zip 11782 Phone (516) 589-2107
1. Total num -r of professional staff 8
Total number of clerical/support staff 13
2. Please attach evidence of current insurance agents'/brokers
errors and ommissions insurance with a minimum limit of
$1, 000, 000.. per occurrence.
3 . Please attach statement certifying compliance with the
..requirements of the Equal Employment Opportunity Acta
(Copy attached)
4 . Is marketing to excess and surplus lines -
(a) Direct yes or
(b) Other areas
5. Please list any special services available (safety, loss
• prevention, claims adjustment, EDP claims, reports, etc. ) :
From within Firm From Insurance Companies or Oth,
Analytical Reports Loss Prevention
Risk Management Claim Adjustments
Analytical Reports
Financing Avaliable
6 . How often will you review claims and reserves with Village?
As often as deemed ,essary by the town dependincr on frequency of
claims minimum would be annually
• r
7 . List in order of preference those markets which your
firm would wish to approach for insurance, showing
servicing office 's current total annual premium volume
for each market.
Liability (Auto and General)
1) AIG 3 Million (Total volume)
2)
Property
1) AIG 3 rrlillion
2)
8. Provide any other information about your firm which
might be pertinent to selection.
• Our firm has been providing comprehensive insurance programs
for manv different clients for over 120 years In that time
we have ins u_rPd several different municipalities
Narde of Person Completing Questionnair,
James F. Hughes
Signature•
Titl
Vice President - Sales
n
NTS' AND BROKERS' ERRORS AND OMISSIONS POLICY
P0L1� 6 3 7 22 8 5
NUMBER 8.05 ME- TT11iliMAN S FUND INSURANCE COMIANfES
COVERAGE IS PROVIDED IN THE FOLLOWING
POLICY 06/04/87 06/04/88 (_It�• COMPANY, A STOCK COMPANY.
PERIOD: FROM TO
(1201 A.M. STANDARD TIME AT PLACE OF ISSUANCE)
O1 '
INSURED'S NAME AND MAILING ADDRESS Firemans Fund Insurance Co.
A.C. EdwardS,' Inc. & A.C.' Edwards Life,
Ltd.' r Or , -
48-50 'Main Street j
Sayville, NY 11782
LIMITS OF LIABILITY AMOUNT DEDUCTIBLE PREMIUM
$ 5009000 EACH CLAIM $ 1 ,500,000 AGGREGATE $ 2,500 EACH CLAIM $ 1
ON INCEPTION DATE FIRST ANNIVERSARY SECOND ANNIVERSARY
INSTALLMENTS ARE PAYABLE $
$ $ .�
In consideration of the stipulations herein named and of the above specified premium, this Company, for the term beginning and ending on the deft shown
above, does insure the above named Insured as herein provided. .
1. Definition of insured. The unqualified word "Insured" includes the named Insured,any partner,director or executive officerthereof while acting in his capacity
as such,and any licensed solicitor or office broker named in the following schedule of additional insureds or other employee employed by the named Insured while
acting within the scope of his duties as such. The individual solicitors or brokers,if any,thus designated in the schedule of additional insureds,shall be additional
Insureds only as respects insurance handled through or placed with the named insured.
Schedule of Licensed Solicitors and Office Brokers as Additional Insureds:
2. Insuring Clause. This insurance,subject to the terms and conditions hereof,will pay on behalf of the Insured all sums which the insured shall become obligated
to pay by reason of liability for breach of duty as Insurance Brokers, Insurance Agents or General Insurance Agents, claim for which is made against them during
the period stated hereinbefore by reason of any negligent act, error or omission, whenever or wherever committed or alleged to have been committed,on the part
of the Insured or any person who has been,is now,or may hereafter during the term of this insurance be employed by the Insured, in the conduct of any business
conducted by or on behalf of the Insured in their capacity as Insurance Brokers, Insurance Agents or General Insurance Agents.
3. EXdlrsions. This insurance shall not apply in respect of any claim
(a) for libel or slander,
(b) brought about or contributed to by the dishonest, fraudulent, criminal, or malicious act or omission of the Insured or any employee of the Insured.
4. tJmlb of Liability. The liability of this Company for each claim shall not exceed the amount shown above as applicable to "each claim," and, subject to that
limit for each claim,the total limit of this Company's liability for all claims covered hereunder and occurring during each policy year shall not exceed the amount
shown above as "aggregate." The inclusion herein of more than one Insured shall not operate to increase the limit of the Company's liability.
S. Deductible Clem. It is understood and agreed that in event of a claim the amount of the deductible shown above shall be deducted from the amount of each
claim payable hereunder when determined. Such deductible shall not apply, however, to supplementary payments as provided under clause (6) of this policy.
ENDORSEMENTS ATTACHED (Continued on Page Two)
135217(9-68) 135296(2-78)
THIS POLICY IS MADE AND ACCEPTED SUBJECT TO THE FOREGOING STIPULATIONS AND CONDITIONS AND TO THE CONDITIONS PRINTED ON THE BACK HEREOF,
WHICH ARE HEREBY SPECIFICALLY REFERRED TO AND MADE A PART OF THIS POLICY, together with such other provisions, agreements or conditions as may be
endorsed hereon or added hereto; and no officer, agent or other representative of this Company shall have power to waive or be deemed to have waived any provi-
sion or condition of this Policy unless such waiver, if any,shall be written upon or attached hereto, nor shall any privilege or permission affecting the insurance
under this Policy exist or be claimed by the Insured unless so written or attached.
IN WITNESS WHEREOF. THE COMPANY HAS CAUSED THIS POLICY 10 BE EXECUTED AND ATTESTED. BUT THIS POLICY SHALL NOT BE VALID
UNLESS COUNTERSIGNED BY A DULY AUTHORIZED REPRESENTATIVE OF THE COMPANY.
SECRETARY PRESIDENT
COUNTERSIGNED AT DATE COU ,fRSIGNATTtJ!E OF /AUTHORIZED AGENT
Vb/cm 5/26/87
�('�
5712-2-65(REV. 8-82) Page 1 of 3
D _
DECLARATIONS SUPERCOVER® UMBRELLA AND EXCESS LIABILITY POLICY
POLICY
NUMBER 8'05 XCG- 16 9 9 5 4 0
POLICY - '•
PERIOD: FROM 6/04/87 TO 6/04/88 t X p iREMAN'S FUND INSURANCE COMPANIES
(12:01 A.M. STANDARD TIME AT THE ADDRESS OF NAMED INSURED
AS STATED HEREIN) CF I
NERAGE S PROVIDED IN THE FOLLOWING
INSURED'S NAME AND MAILING ADDRESS C, E A GE A STOCK COMPANY.
A. C. Edwards, Inc. & A. C. Edwards Life, 0 Fireman' s Fund Insurance Co.
Ltd.
48-50 Main Street
Sayville, NY 11782
LIMITS OF LIABILITY
$ 4,000,000 EACH OCCURRENCE
$ 4,000,000 AGGREGATE
PREMIUM
BASIS OF PREMIUM
Flat Charge
ADVANCE PREMIUM ANNUAL MINIMUM PREMIUM
$ 9,179 $ 9,179
SCHEDULE OF PRIMARY INSURANCE
THIS SCHEDULE IS DESCRIBED WITHIN FORM NO. 175045-12-80 WHICH FORMS A PART OF THIS POLICY'S DECLARATIONS.
ENDORSEMENTS ATTACHED TO AND FORMING A PART OF THIS POLICY AT INCEPTION:
175045, 175064, 175130
DATE OF ISSUE COUNTERSIGNATURE OF AUTHORIZED AGENT
n 87
THIS DECLARATIONS PAGE IS ISSUED IN CONJUNCTION WITH ND FORMS A PART OF POLICY FORM 5846
5163--06-82
IRV
INSURED -,..
PRODUCER
EFFECTIVE DATE
ITEM 6 OF THE POLICY DECLARATIONS IS COMPLETED TO READ AS FOLLOWS:
TYPE OF POLICY
LIMITS OF LIABILITY
F. INSURANCE AGENTS' AND BROKERS'
ERRORS AND OMISSIONS
COMPANY: Fireman's Fund Insurance Co.
POLICY NO. : ME 637 22 85 $ 500,000 EACH OCCURRENCE
$1,500,000 AGGREGATE
EXPIRATION DATE: 6/04/88
175045-12-80(REV)
STATE OF N EW YORK, INSURANCE DEPARTMENT-BROKER'S LICENSE UNDER SECTION 2104,INSURANCE LAW
THE SUPERINTENDENT OF INSURANCE OF THE STATE OF NEW YORK,BY VIRTUE OF THE AUTHORITY VESTED IN HIM BY
SECTION 2104 OF THE INSURANCE LAW,DOES HEREBY AUTHORIZE THE LICENSEE NAMED BELOW TO ACT AS BROKER IN OBTAINING AND 13 0 9
PLACING INSURANCE UPON PROPERTY AND RISKS IN THE STATE OF NEW YORK.AS PROVIDED IN SAID SECTION UNTIL THE EXPIRATION
DATE SHOWN HEREON,UNLESS THIS LICENSE IS SOONER SUSPENDED OR REVOKED. CORPORATION
THIS LICENSE'EXPIRES` LICENSE NUMBER
FORM 7W E D W A R D S A C
43MAIN ST P F3,0X-4Z3' f"'' 060185
SAYVILLE NY 17
IF PARTNERSHIP OR CORPORATION,BY AND THROUGH THE SUB-LICENSEES)NAMED ON ATTACHED CARDS
�n �ltriess 3�herenf, ICA
987
1 HAVE CAUSED MY OFFICIAL
S TO BEA FIX D AT THE CITY OF ALBANY ( p({C Q R A �J
J A t'I E SUdERiNYERDEN70F MSUFtANCE
I
STATE OFNEW YORK,ORK, INSURANCE DEPARTMENT-PARTNERSHIP OR CORPORATION SUB-LICENSEES AUTHORIZED TO ACT UNDER 39664
EXPIRES
TITLE LICENSE NUMBER
DANES JOHN R
ROCERS PETER 060185
SUB ROCERS. GEORGE
LICENSEES R A C H. STEPHEN E
FORM 798
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4r�
t Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
JUDITH T. TERRY TELEPHONE
TOWN CLERK (516) 76S-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
September 25, 1987
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
William C. Southwick, President
Griffing 8 Southwick, Inc.
55 North Ferry Road
Shelter Island, New York 11964
Dear Mr. Southwick:
Your Pre-Qualification Questionnaire has been received and the Town
hereby approves the utilization of the carriers you so designated.
Enclosed herewith are the Insurance Specifications and Loss Information.
Please note that the bids are required to be received by this office on
or before November 30, 1987.
Very truly yours,
4-01 _
Judith T. Terry
Southold Town Clerk
Enclosures
cc: W. Mullen `
.d,
iSENDER:Cgln leJ. Terry
!a items 1 acid 2 when additional services are desired,and complete items 3 and 4. P 263 05t 136
your addresi"RETURN TO"space on the reverse side.Failure to do this will prevent this y,
r om being resumed to you.Ther rn receipt fee will r of he n
e rad tooand a olive. or additional fees the o lowia rvIces are we e.Consult
aster for ox'(#$)for additional service(s)requested.
Show to whom doliveri date,and addressee's address. 2. Il Restricted Delivery. .
,: .Article Addressed to: 4.Article Number William C. Southwick, President
William C. Southwick, President
P 263 057 136 Griffing 5 Southwick, Inc.
ni�ceo
Griffing E Southwick, IncType of 96 Inc. Type ❑❑ 55 North Ferry Road
55 North Ferry Road cerrtl-f ❑ Coosa
Shelter Island, N.Y. 11964
Shelter Island, New York 11964 Express Mail
Always obtain signature of addressee or
agent and DAYE_DELIV&RED.
5.Si ur Addresse 8.Addressee's Address(QNLY if
X requested and fee paid) '
8.Signature—Agent
X _
7.Date of Delivery
PS Form 3811,Feb.1986 DOMESTIC RETURN RECEIPT25
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Town Hall, 53095 Main Road
e h �� P.O. Box 1179
Southold, New York 1 1971
JUDITH T. TERRY TELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
September 25, 1987
CERT I FI ED MAI L
RETURN RECEIPT REQUESTED
John V. Stype, Secretary-Treasurer
Val Stype 8 Sons, Inc.
Main Road, P. O. Box 63
Mattituck, New York 11952
Dear John:
Your Pre-Qualification Questionnaire has been received and the Town
hereby approves the utilization of the carriers you so designated.
Enclosed herewith are the Insurance Specifications and Loss Information.
Please note that the bids are required to be received by this office on
or before November 30, 1987.
Very truly yours,
Judith T. Terry
Southold Town Clerk
Enclosures
cc: W. Mullen
.
•SENDER:Complete items land 2 when additional services aro desired,and complete items 3 and J Terry P 6 3 0 5 7 1 7
Put your address in the"RETURN TO"space on the reverse side.Failure to do this will prevent this
card from being returned to you.The rourvabdo , eaia
onsulte
delivered to and the date of delivery. or dtwee
postmaster or fees and check box es)for additional service(s) requested.
1. ❑ Show to whom delivered,date,and addressee's addrq j. 2. Q RZ d Delivery. ! John V. Stype,Secretary-T reas u re
3.Articla A dressed to: 4.Artiiscle Number Val Stype & Sons, Inc.
P 263 057 137
John V. Stype, Secretary-Treasure Type of Service: Main Road, P. O. Box 63
Val Stype & Sons, Inc. Registered pQ Insured
Main Road, P. O. Box 63 Certified L1 COD• Mattituck, New York 11952
Mattituck, New York 11952 Ex reseMail
Always obtain signature of addressee or
agent tlnd QA Q IVE E
5.Signature— ssee 8. ressee's Address//ON
X requested and fee pat`df i
i
S.Sip
X
7.DjWcf Delivery
-a r 8 7otio
PS Form 3811,Feb.1986 DOMESTIC RETURN RECEIPT
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,,. .. Town Hall, 53095 Main Road
P.O. Box 1179
°�( t Southold, New York 11971
JUDITH T. TERRY TELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
September 25, 1987
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
Robert J. McCarthy, Vice President
Roy H. Reeve Agency, Inc.
P. O. Box 54, Main Road
Mattituck, New York 11952
Dear Bob:
Your Pre-Qualification Questionnaire has been received and the Town
hereby approves the utilization of the carriers you so designated.
Enclosed herewith are the Insurance Specifications and Loss Information.
Please note that the bids are required to be received by this office on
or before November 30, 1987.
Very truly yours,
Judith T. Terry
Southold Town Clerk
Enclosures
cc: W. Mullen
•SENDER:Complete items 1 and 2 when additional services are desired,and complete items 3 and 4. •T erryP 263 G -17 138
Put your address in the"RETURN TO"space on the reverse side.Failure to do this will prevent this
card from being returned to you.The return recei t fee will r f me fthe rson
delivered to and the date of deliva' or additional ees t e o ow ng" rvicea are availab e.Consult
postmaster for fees and check box es)for additional service(s)requested.
1. ❑ Show to whom delivered,date,and addressee's address. 2. ❑ Restricted Delivery. '
3.Article Addressed to: 4.Article Number Robert J. McCarthy, Vice Pres den
P 263 057 138 :Zoy H. Reeve Agency, Inc.
Robert J. McCarthy, Vice President Type of Service: 3 P. O. Box 54, Main Road
Roy H. Reeve Agency, Inc. ❑ Registered Insured
P. O. Box 54, Main RoadCertified COD Mattituck, New York 11952
Mattithlc New York 11952 Express Mail
Always obtain signature of addressee or
agent and DATE DELIVERED.
S.Signa dressee S.Addressee's Address(ONLY if
X requested and fee paid)
6.Sig lure—Agent
X
7.Date f Deli r�
o
PS Form 3811,Feb.1986 DOMESTIC RETURN RECEIPT
i
SEP
25
' 198 tiv
'QFC•U
I
i
T O W N O T S O U T H O L D
• I N S U R A N C E S P E C I F I C A T I O N S
I N D E X
PAGE
Gen8k&I Information . . . . . . . . . . 1 to 4
Risks to be Insured . . . . . . . . . . 5 to 11
Buildings and Contents (Locations and
- Valuations) . . . . . . . . . . . 12 to 13
Vehicles - Automobile Liability
Insurance . . . . . . . . 14 to 18
Contractors Equipment . . . . . . . . 191
Current Insurance Schedule . . . . . 20 to 28
Loss Information . . . . . . . . . . 29
Premium Quotation . . . . . . . . . . 30 to 34
•
September 1987
• ! 1
TOWN OF SOUTHOLD
I. General Instructions
The Town - of-_Southold is interested in receiving proposals
on its property and liability insurance programs, in accordance
with specifications attached to take effect on January 1,
1988. The purpose of the specifications is to provide the
Twon with an insurance program which involves improved pricing,
broader coverage, and if to the advantage of the Town, _ fewer
policies and carriers. While imagination and innovation are
encouraged, all suggestions which differ from the general
specifications should be presented as alternatives in the
proposal, and will be considered. Also, where coverage proposed
is less than or greater than indicated in the specifications,
• it should be noted in your proposals.
It is the intent of the Town to establish or continue
a long-term relationship with one or more insurance companies.
It is anticipated that a subsequent quotation procedure will
not be carried out for at least three years. While the town
prefers to have the insurance program coordinated by one agent/broker,
it will accept proposals encompassing less than the total
insurance program outlined herein. The Town also reserves
the right to deal directly with any association that will
be to their advantage as to cost and coverage.
The underwriting, exposure, loss date and other information
furnished by the Town and its current agents and underwriters
have be compiled from available statistics. If you desire
• additional informatin or have questions regarding the material
contained herein, please write to Mr. William F. Mullen, Jr. ,
• 2
Risk Manager, Town of Southold, 53085 Main Road, P.O. Box
• 1179 , Southold,:,NewYork 11971. Mr .Mullen served as consultant
to the Town in preparing the enclosed insurance specifications
and will be assisting in the evaluation of insurance proposals.
Qualifications and Requirements for Insurance Companies
Any insurance company used by an agent or quoting directly
shall:
1. Be qualified and/or licensed in the State of New
York (non-admitted or surplus lines companies shall be on
the approved iist:)of the New York State Insurance Comssioner) .
Insurance agents/brokers selected to submit proposals
on the Town insurance program will be assigned insurance markets
to prevent prospective insurance underwriters from receiving
proposal requests from more than one agent/broker. Following
• the final selection of the agent/broker to handle the Town
insurances, that agent/broker will have access to the total
market place in order to secure the broadest and most reasonably
priced insurance.
General Conditions for . ail Quotation:- Proposals
1. Sealed quotations shall be submitted in writing on
or before November 30, 1987 to the Town of Southold
53095 Main Road, P.O. Box 1179 , Southold, New York, 11971
Attention: Judy Terry, Town Clerk. All quotations will be
opened at 11: 00 a.m. on Dec,- 1,. '1987 Quotes -.will be reviewed
and a, decision made on or about Dec? 3, 1987]
2. Quotations shall be in.dupiicate, following the format
of these specifications.
• 3. The effective date of coverage will be January 1,
1988, unless otherwise stated. The companies awarded the
• 3
business shall provide a signed binder on or before December
• 18, 1987, and deliver policies within a reasonable time there- :
after.
4. The Town requests that the term of all contracts
by three years -except fof policy terms limited by law.
5. A total quotation is requested from each agent for
all coverage, limits, and levels of retention. The preference
is for one insurer rather than several and for the user:of
a "package" policy where possible.
6. The Town reserves the right to accept or reject any
and all proposals and to select the one it deems to provide
the best coverage at the most favorable price, in relation
to the service provided. The Town also encourages initiative
and imagination in developing the boradest possible proposal
• consistent witha reasonable price. Guiddlines and underwriting
data provided are not intended to limit flexibility of proposals.
7. Transition Period Services - The agent/broker awarded
the program will be expected to work with the Town to incorporate,
cancel or eliminate all existing policies which will be included
under the new program.
II. Overall Policy Standards
The following general policy standards will apply to
all proposals:
1. Named Insured__- All property policies shall be issue&I
in the name of Town of Southold, New York. Ih addition to
the above, liability policies are to include as insureds:
"All elected or appointed boards and commissions, officials,
officers, employees, and volunteers, both individually and
collectively, when acting or deemed by a majority of the
Tonw Board to have been acting within the scope and performance
4
of their duties for the Town" .
• 2. NOtice of Cancellation - All insurance contracts
should contain provisions_�for a minimum of 60 days' prior
written notice of cancellation, non renewal, material increase
in rate or material reduction in coverage. Such notice shall
be given to the Town Clerk - Town of Southold, 53095 Main
Road, P.O. Box 1179, Southold, New York, , 11971.
3. Premium Payments -Policies are requested to be written
on a three year basis, if possible, with premium payments
in annaual installments. Monthly installments are preferred
on package policies or single contracts with large premiums,
with no finance charges.
4. Loss Adjustments - All ]posses should be adjustable
with an payable to the Town of Southold. .;.An endorsement shall
• be attached--to each policy providing that the time £or proper
notification to the insurance company begins only after the
Supervisor and Councilpeople and Town Clerk have knowledge
of the event.
5. Policy Dates - All insurance -policy contracts should
expire on January 1.
6. Rating - _The Town prefers composite rating where
possible, using estimated tax revenues of $10, 000, 000; payrolls
for an estimate from January 1988 to 1989 of $5 , 000 , 000 or
approximate population of 22, 000 for liability rating.
7. Coverage afforded by all the insurance policies
shall not be invalidated or affected by an inadvertent error,
• ommisssion, or improper descriptions mentioned in the specifications.
• 5
A. Buildings and Contents
aBuildings
Total Exposure $1000:: Deductible
$4,522, 600
Contents:
Total Exposure $1000 Deductible
$1, 065, 000
1. Perils;
Proposals shall be quoted against all risks of direct
physical loss except as specifically excluded, but must provide
fire, extended coverage, and vandalism and malicious mischief.
2. Valuation - Real and personal property are on a
replacement - cost basis.
• 3. Deductible -
$1, 000 per occurence
B. Extra Expense:
1. Coverage -
Fire, extended coverage, vandalism, and malicious mischief
including all risk for the
(a) Town Hall - (location #1)
(b) Police Station ( location #12)
(c) Highway Office and Garage (location #7)
2. Limit. of $50 , 000 per location, each of above location.
3. Deductible - Subject to common deductible for buildings
and contents.
6
•
C. Boiler and Machiner Insurance:
1. Broad-form blanket group coverage per location #1
and 12, boiler and machinery object list.
2. Limits - $l :million per occurrence.
3. Deductible - $5, 000
4. Valuation - Replacement cost basis.
5. Obtain a joint loss agreement whereby if property
and boiler and machineryinsurers are different, they agree
that if neither admits liability, each will advance on half
the loss and then work out the actual apportionment between
themselves.
6. Locations -
• (a) Town Hall Main Road, Southold, N Y.
(b) Police Station, Main Road, Southold, N. Y.
D. Valuable Papers Insruance -
Location Town Hall - 53095 Main Road, Southold, New
York 11971
Limit on premises - $500, 000
Limit off premises - $10, 000
E. Comprehensive General Liability Insurance:
1. The premium should be determined by using the simplest
rating basis possible, preferably the 1988 payroll or the
Town tax revenue.
2. Limits
• (a) Bodily injury and property damage: $500, 000
combined single limit per person and per occurrence or $1, 000, 000
CSL.
7
•
3. Coverage to pay on behalf of insured for all sums
which insured may be liable, including defense costs.
4. Products and completed operations to be included.
5. At least provide broad form peroperty damage or eliminate
the care, custody or control exclusion.
6. Liability arisingc;out:_of the use of unlicensed vehicles
including all owned or leased mobile equipment is to be included.
Such vehicles and equipment shall not be deemed automobiles.
7. Personal Injury - A, B, and C should include: false
arrest, detention or imprisonment, malicious prosecution,
libel, slandeir, deleting exclusion "C" .
8. Blanket Contractual Liability -_- Preferable for both
• written and oral contracts and agreements, defamation of character,
invasion of privacy, wrongful eviction, wrongful entry, assu alt
and battery payment of damages for care and loss of services,
mental anguish, fright, humiliation, discrimination, or any
other injury that nay person may suffer to his person,reputation,
character, feeling or estate. Standard personal injury exclusion
"C" should be deleted.
9. Employee Benefit Program
10. Fire, ,Legal Liability - Real property, $50 , 000 limit.
11. Independent contractors - and subcontractors are to
be included as additional insured to the extent their liability
insurance is adequate.
12. Eliminatd the XCU exclusion, except that it may be
• applied to specific construction, to be defined.
8
• 13. Premises, whether or not declared, and operation.
14. Incidental medial malpractice coverage.
15. Host liquor liability endorsement is to be added
to the contract.
16: Additional insured employee, including volunteers
17. Additional insured should include any person,
organization, trustee or state to who or to which the Town
is obiligated by virtue of a written contract to provide
insurance as afforded by the policy.
18. Fellow member liability.
F. Automobile Insurance:
1. '-'Fleet automatic" basis for all vehicles, with a
summary of- changes to be reported annually. 90 day coverage
• for leased vehicles provided lease reported within 90 days.
2. Vehicles to be Insured.`- All Town vehicles (including
vehicle number, make, model,year, body type ) to be insured
for liability.
3. Limits
(a) Bodily injury and property damage: combined
single limit .$500, 000 per person and per occurrence or $1, 000, 000
C. S.L.
4. Coverage - Bodily injury and property damage arising
out of owned, hired, and non-owned vehicles.
5. Policy to comply with all New York requirements including
uninsured motorist and New York no fault requirements.
•
9
6. Physical damage coverage - Comprehensive, fire and
theft and collision, scheduled items , number 7, 10 , 20 , 24 ,
25, 26, 30, 31, 32, 37, 39 , 41, 42, 43, 50 , 51, 53, 54, 55 ,
56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 6.9, 71, 72,
73, 74, 75, 76, 77 , 78, 79 , subject to a $500 deductible.
G. Contractor' s Equipment Floater:
1. Coverage on all "all risk' basis.
2. Provide coverage basisom .an annual adjustment
form which provides automatic coverage for all owned, acquired,
or leased equipment including newly-acquired equipment and
which does not have co-insurance requirements.
3. Limits - $1, 580, 392 policy limit involving items.
4. Retention - Price is required on $1, 000 deductible
• per occurrence.
5. Liability coverage for all contractor' s equipment
should be provided, whether licensed or unlicensed.
6. Co-insurance requirements - 80% or if agreeable with
underwriter, void any co-insurance requirement.
H. Umbrella Liability Insurance:
1. Limits - Bodily injury and property damage - combined
single limit. (1) $1 million (2) $2 million (3) $3 million (4) $4 millic
per occurrence with a total umbrella aggregate of $5 million.
2. Self-insured retention of $10 , 000 per occurrence
where underlying insurance is not provided.
3. Includes defense and settlement within retention
when primary limits are exhausted.
• 4. Coverage for owned and non-owned watercraft.
5. Form to be "pay-on-behalf-of" rather than indemnif-
10
• ication form, if possible.
6. Specific information regarding restriction of coverage ,-,
or broader coverage than underlying protection _is required.
I. Police Professional Liability:
Limits: $1, 000, 000 each person
$1, 000, 000 each incident
$1, 000, 000 aggregate
The Town of Southold Police Department currently consists
of 37 full and 4 part-time officers. In addition. we have
2 full-time Bay Constables and 4 part-time Bay Constables.
Naturally, the Town must also be considered as named insured.
J. Public Employee Blanket Bond and Crime
$25, 000 - Insuring Agreement 4 - Blanket Position Bond
• Additional Indemnity
Title Excess Total
Supervisor $190, 000 $215, 000
Deputy Supervisor 190, 000 215, 000
Tax Receiver 75, 000 100, 000
Town Clerk 50, 000 75, 000
Money, Securities - Insuring Agreemnt II and III
Premises - (a) $25, 000 - In and Out Coverage
(b) $50, 000- - During the months of
December, January, and
May - In and Out Coverage
K. Hull Coverage
$500, 000 Protection and Indemnity
Vessels Value
• 1. 1981 24 ' Privateer W 150 HP $35, 000
2. 1967 13 ' Boston Whaler W 40 HP 35, 000
• , 11
Vessels Value
• 3. 1983 23 ' Sea Ox W 200 HP $15, 000
4. 1986 18 ' Steigcraft W 90 HP 15, 000
Deducitble $500
The only vessel utilized for more than six (6) months
is the 1981 Privateer. All other units are for the period
of April 15th - October 15th, unless advised to the contrary.
L. Public Official Liability
Limits: $1,000, 000 each loss
$1, 000, 000 annual aggregate
•
•
12
BUILDINGS AND CONTENTS - LOCATIONS AND VALUATIONS
• BUILDINGS CONTENTS
1. Town Hall - Main Road, Southold, NY $1, 250, 000 $250, 000
2. Town Beach - North Rd. , Rte. 48, Southold, NY 16, 200 -----
3. Animal Shelter - Main Road, Peconic, NY -54, 000 -----
4. Animal Shelter - Main Road, Peconic, NY 21, 600 -----
5. Landfill - North Road, Rte. 48, Cutchogue, NY 250, 000 30, 000
6. Equip. Test - North Road, Rte. 48, Cutchogue, NY 37, 800 -----
7. Hwy. Off. and Gar. - Peconic Lane, Peconic, NY 750, 000 250, 000
8. Storage and Gar. - Peconic Lane, Peconic, NY ,50, 000 5, 000
9. Garage - Peconic Lane, Peconic, NY 300, 000 25, 000
10. Lawn Mower Repair - Peconic Lane, Peconic, NY 40, 000 20, 000
11. Salt Storage - Peconic Lane, Peconic, NY 40, 000 10, 000
12. Police Station - Main Road, Peconic, NY 400;000 200;000
03. Radio Tower, - Main Road, Peconic, NY 10, 000 ----
14. Senior/Youth - Peconic Lane, Peconic, NY 351, 000 15, 000
15. Scavanger Water - Moore' s Lane Greenport, NY 500, 000 250 , 000
Building #2 250, 000 ------
16. Tourist Bldg. - Main Road, Laurel, NY 75, 000 ------
17. Klipp Beach - Greenport, NY 25, 000 ------
18. McCabes Beach - Southold, NY 25, 000 ------
19. Kenney' s Beach - Southold, NY 25, 000 ------
20. Goose Creek, Southold, NY 25, 000 - ------
21. New Suffolk Beach, New Suffolk, NY 25, 000 ------
22. Frame Storage Trailer - w/s Peconic Lane, Peconic, NY 2, 000 10, 000
TOTAL $4,.522, 600 $1 .p65, 000
• TOTAL BUILDINGS AND CONTENTS $5, 587, 600
13
• The Town would consider blanket coverage on buildings and
contents for any one occurence for a valuationof threemillion
dollars ($3, 000 , 000) on the basis naturally of no cot4insurance.
•
•
14
VEHICLES
EH YEAR MAKE/MODEL/BODY TYPE VIN '..'CLASS
1 1981 Chev/Building Department 2G1AL35J6Bll50063 1998
2 1968 Jeap/Highway Dept. 29859 01499
3 1982 Ford/Highway Dept. 2FABP35F5CB21223 1998
4 1978 Ford/Highway Dept. /Pickup F26HECE1535 1998-,
5 1982 Plymouth/Police Dept. 2P3BB26L2CR133594 7911
6 1984 Plymouth/Police Dept. 1P3BB26P3EX542615 7911
71 1984 Plymouth/Build s*g. Del)t. 1P3BB26S7EX580532 1998
Comp Ded: $500 Coll Ded: $500 ACV
8 . 1984 Plymouth/Building Dept. 1P3BM18C4ED275873 1998
9 1984 Plymouth/Community Development 1P3BM18C2ED302293 1998
10 1982 Chevrolet/Highway Dept. /4 Dr. Sed. 1G1AW68K3CB183180 03499
11 1966 Int. /Public Works/Dump 211912G205375 01479
�2 1956 Intl. /Highway Dept. RD40666889 01479
13 1969 Intl. /Highway Dept. 717911G329500 01499
14 1972 Intl. /Highway Dept. 707211G475279 01499
15 1973 Intl. /Highway Dept. 70721CGB11058 01499
16 1974 Intl. /Highway Dept. 70721DGB13421 01499
17 1975 Ford/Highway Dept. F37YEV63895 01499
18 1977 Dodge/Highway',Dept. D81GR7J001431 01479
19 1977 Dodge/Highway Dept. D81GR7J001432 01479
20 1981 Chev/Highway Dept. 1GBJC34M8BV101386 01479
Comp Ded: $500 Coll Ded: $500 ACV
21 1981 Chev/Highway Dept. 1GBJC34M2BV101383 01479
22 1978 Intl. /Highway Dept. DI22EGBI8578 _ 21479
23 1970 Intl. /Highway Dept. 707211G374933 21479
24 1979 Intl. /Highway Dept. CA252JHA33268 21479
• Comp Ded: $500 Coll Ded: $500
15
VEHICLES
EH YEAR MAKE/MODEL/BODY -'TYPE VIN CLASS
25 1981 Intl. /Highway Dept. CA255BMA10967 21479
Comp Ded: $500 Coll Ded: $500 ACV
26 1981 Intl. /Highway Dept. 1TKCA2556BHA27031 21479
Comp Ded: $500 Coll Ded: $500 ACV
27 1977 Ford/Highway Dept. FlDGEY44701 01499
28 1966 Intl/Public Works Sander FD112534H 01499
29 1971 Broakway/Public Works 72488 23499
30 1984 Steco/Public Works/Trailer 1S9ESR2T4E1007077 68499
Comp Ded: $500 Coll Ded: $500 ACV
31 1984 Steco/Public Works/Trailer 1S9ESR2T2E1007076 68499
Comp Ded: $500 Coll Ded:. $500 ACV
32 1984 Ford/Highway Dept. 1FDYK8040EVA05820 21479
Comp Ded: $500 Coll Ded: $500 ACV
33 1982 Dodge/Highway Dept. JB7FP2474CY704104 01499
404 1983 Dodge/Highway Dept. JB7FP2472CY704067 01499
35 1982 Dodge/Highway Dept. 2B7FB13E6CK173879 01499
36 1983 Dodge/Nutrition 2B4HB23HODK353964 01499
37 1984 Chev/Highway Dept. 1GBHC34M6EV127732 01479
Comp Ded: $500 Coll Ded: $500 ACV
38 1984 Dodge/Maintenance JB7FP24D6EY700869 03499
39 1984 Chev/Highway Dept 1GBMC34M3EV127963 01479
Comp Ded: $500 Coll Ded: $500 ACV
40 1971 Ford/Highway Dept. F90HVM142276 21479
41 1978 Plym/Nutrition/Van BC2BE8K1246621 6489
Comp Ded: $500 Coll Ded: $500 ACV
42 1980 Dodge/Nutrition B32JEAK111393 6489
Comp Ded: $500 Coll Ded: $500 ACV
43 1980 Plym/Nutrition BC6KTAK137973 6480
Comp Ded: $500 Coll Ded: $500 ACV
44 1985 Plym/Police Dept. 1P3BB26S3F632773 1998
ACV
05 1985 Plym/Building Dept. 1P3BB26S1FX632772 1998
16
• VEHICLES
VEH YEAR MAKE/MODEL/BODY TYPE VIN CLASS
46 1985 Plym/Police Dept. 1P3BB26SXFX632771 1998
. ACV
47 1985 Ford/Police Dept. 1FMDU15H1FLA87985 03499
ACV
48 1977 Ford/Fishers .Island Ferry E14HH240410 21499
ACV
49 1985 Plymouth/Police Dept. 1P3BB26PXFX652563 1998
ACV
50 1985 Intl. /Highway Dept. 1HTZLTVR4FHA58099 33499
Comp Ded: $500 Coll Ded: $500 ACV
51 1985 Ford/Wastewater Disposal 1FDNF60H4FUA71660 33499
Comp Ded: $500 Coll Ded: $500 ACV
52 1986 Dodge/Building Dept. 1B3BZ18C8GD159209 1998
ACV
�3 1985 Intn'-1.:'Harves/Public Works.. 1HTLAHEMlFHA61054 21499
Comp Ded: $500 Coll Ded: $500 ACV
54 1986 Dodge/Assessors 2B4FK41G2GR775002 1998
Comp Ded: $500 Coll Ded: $500 ACV
55 1986 Chev/Highway Dept. 2GCEK24L5Gll93017 01499
Comp Ded: $5, 000 Coll Ded: $500 ACV
56 -1 _:1986 Chev/Highway Dept. 2GCEK24L8Gll93013 01499
Comp Ded: $500 Coll Ded: $500 ACV
57 1986 Chev/Highway Dept. 2GCEK24L4Gll93042." 01499
Comp Ded: $500 Coll Ded: $500 ACV
58 1987 Plymouth/PolicsDept/Fishers Island 1P3BB26S2HX716344 7911
Comp Ded: $500 Coll Ded: $500 ACV
59 1987 Plymouth/Police Dept. 1P3BB26S4HX716345 7911
Comp Ded: $500 Coll Ded: $500 ACV
60 1987 Plymouth/Police Dept. 1P3BB26S8HX716347 7911
Comp Ded: $500 Coll Ded: $500 ACV
61 1987 Plymouth/Police Dept. 1P3BB26SOHX716343 7911
Comp Ded: $500 Coll Ded: $500 ACV
•62 1987 Plymouth /Police Dept. 1P3BB26S6HX716346 7911
Comp Ded: $500 Coll Ded: $500 ACV
17
VEHICLES
YEAR MAKE/MODEL/BODY TYPE VIN CLASS
63 1987 Plymouth/Police Dept. 1P3BB26SXHX716348 7911
Comp Ded: $500 Coll Ded: $500 ACV
64 1946 International/Highway Dept. /Snow Go 41951 01499
65 1981 Hyster/Highway Dept. /Trailer 1HKMEGLA9BCO2401 67499
Comp Ded: $500 Coll Ded: $500 ACV
66 1987 Dodge/Nutrition Center/B-350 Wagon 2B5WB31TXHK279992 6489
Comp Ded: $500 Coll Ded: $500 ACV
67 1987 Dodge Ram 50/Public Works/Pickup JB7FL29E8HP049266 01499
Comp Ded: $500 Coll Ded: $500 ACV
68 1981 Dodge/Police Dept Bay Constable/4 W 1B7HW14T8HS459174 7911
Comp Ded: $500 Coll Ded: $500 ACV
69 1986 Ford/Nutrition/Van 1FBHE21HXGHB59984 01499
Comp`l.Ded: $500 Coll Ded: $500 ACV
70 1973 Ford/Highway Dept. /Van N76FVS46164 01499
ACV
�1 1987 Plymouth/Police Dept/Gran Fury 1P3BB26P3HW113887 1998
Comp Ded: $500 Coll Ded: $500 ACV
72 1987 Plymouth/Police Dept. /Gran Fury 4D 1P3BB26S2HW109964 7911
Comp Ded: $500 Coll Ded: $500 ACV
73 1987 Plymouth/Police Dept. /Gran Fury 4D 1P3BB26S4HW109965 7911
Comp Ded: $500 Coll Ded: $500 ACV
74 1987 Plymouth/Police Dept. /Gran Fury 4D 1P3BB26S6HW109966 7911
Comp Ded: $500 Coll Ded: $500 ACV
75 1987 Plymouth/Police Dept. /Gran Fury 4D 1P3BB26S8HW109967 7911
Comp Ded: $500 Coll Ded: $500 ACV
76 1987 _.:Dodge/Police Dept. /Diplomat 4DR SDN 1B3BG2645HW137777 7911
Comp Ded: $500 Coll Ded: $500 ACV
77 1987 Plymouth/Police Dept. /Gran Fury 4D 1P3BB26S1HW109969 7911
Comp. Ded: _ ;$500 Coll Ded: $500 ACV
78 1987, Dodge/Jiwy.Dept. Fishers Island/Dum 1B6MD3453HS467883 01479
Comp Ded: $500 Coll Ded: $500 ACV
79 1984 Plymouth/Reliant/Public Works/Subur 1P3BP49C7EF290086 1998
• Comp Ded: $500 Coll Ded: $500 ACV
18
TOWN OF SOUTHOLD
• Auto Codes
1998 Private passenger
7911 Police
01499 Light, service, local
01479 Light, service, local, dump
03499 Light, Commercial, local
21499 Medium, service, local
21479 Medium, service, local, dump
23499 Medium, commercial, local
33499 Heavy, commercial, local
68499 Social,-.'.Service Automobile,
employee operated
67499 Semi-trailer, local
•
•
19,
• CONTRACTORS EQUIPMENT
Description Value
1. Caterpiller Bull Dozer
MDLD6D#4X9006 $ 92, 198
2. 1981 International Payloader #3268 140, 000
3. Mbrback Super Beaver Chipper and Attachments 53, 475
4. Brown Bear Cub Tractor with Compost Auger
and Brush 74, 706
5. 1975 Ford Payloader # 447259 31:;8!4
6. Dynahoe Backhoe # D190-D50417E 78, 400
7. 1981 Mobile Sweeper # 820-4-1263 53, 787
8. 1979 Fiat Payloader # 145C64M04089 130, 000
9. 1985 Mobile Sweeper #59049 81, 078
10. WHO Tub Grinder with Caterpiller Diesel #601 112, 000
• 11. 1985 Komaster Payloader #50212 110, 000
12. 1980 International Payloader 63, 000
13. 1982 Ford Tractor 28, 700
14. Cardinal Scale and Equipment 150, 000
15. 1987 Cateppiller Model # 8168 #152662 181, 000
TOTAL $1, 383, 278
In addition to the scheduled items there are fifteen (15)
other piecesof equipment valued at $197, 114 for a total overall
valuation of $1, 580, 392.
•
20
SCHEDULE OF INSURANCE
•
C N' A 1P302394469 01/01/87 - 01/01/88
COMMERCIAL PACKAGE
GENERAL LIABILITY LIMITS
Liability
Combined Single Limit $500 , 000 per occurrence
$500, 000 aggregate
Premises Medical $1, 000 Person
$10, 000 Accident
Personal Injury "A" "B" "C"
Coverages:
Conprehensive General Liability
Contractual: Blanket
•
•
21
• C N A 102027573 01/01/87 - 01/01/88
Commercial Auto
BUSINESS AUTO LIMITS
Liability
Combined Single Limit $500, 000
Personal Injury Prot $50, 000
Uninsured Motorists $10, 000/20, 000
Comprehensive See Schedule
Collision See Schedule
Hired/Borrowed
Auto Liability States: New York
Emp. Non-ownership
Auto Liability States: New York
•
•
• 22
EXCESS COMPANIES PE51899 11/17/86 - 11/17/87
• E&O, D&Q, MISC LIABILITY
RISK ID ITEM COVERED/DESCRIPTION
270 Public Officials Liability
FORMS/CONDITIONS/ENDORSEMENTS:
TU PE 673 Hiring and Firing Exclusion
TU PE 658 Failure to Maintain Adequate Insurance Exclusion
TU PE5101 Discrimination Exclusion
TU PE 601 Prior Litigation Exclusion
LIMITS DEDUCTIBLE
Public Officials $1, 000 , 000 $10 , 000 01/01/87- 01/01/88
• Liability $1, 000
•
23
ST. PAUL FIRE & MARINE 365JF7036 01/01/87 - 01/01/88
• COM'L.LINLAND MARINE
CONTRACTORS EQUIPMENT FLOATER
CONTINENTAL INS. CO. BND2252995 01/01/85 - 01/01/88
COMMERCIAL BONDS
RISK ID ITEM COVERED/DESCRIPTION
A Bond
Public Employees Blanket Position Bond
FORMS/CONDITIONS/ENDORSEMENTS:
Specific Positions: Supervisor $190, 000
Deputy Supervisor: $190 , 000
• Tax Receiver: $75, 000
Town Clerk: $50, 000
LIMITS
Bond Limit $25, 000
•
24
EXCESS COMPANIES PPL3335220 01/01/87 - 01/01/88
• E&0, D&O, MISC LIABILITY
RISK 113 ITEM COVERED/DESCRIPTION
A Police Professional Liability
FORMS/CONDITIONS/ENDORSEMENTS:
$1, 000000 each incident
no aggregate
LIMITS DEDUCTIBLE
Police Professional $1, 000, 000 $5, 000 01/01/87 - 01/01/88
•
•
• 25
EXCESS COMPANIES UMB6002251 01/01/87 - 01/01/88
• COMMERCIAL UMBRELLA
RISK ID ITEM COVERED/ESCRIPTION
A Commercial Umbrella
FORMS/CONDITIONS/ENDORSEMENTS:
$10'000. Retained Limit
LIMITS
Comm' l Umbrella $1, 000 , 000
•
•
26
EXCESS COMPANIES POH211987 01/22/87 - 01/22/88
• COMMERCIAL BOAT
RISK ID ITEM COVERED/DESCRIPTION
_A Marine Coverage
Protection & Indemnity
LIMITS
Liability $500 , 000
•
•
27
C N A 80010276 01/07/87 - 01/07/88
• COMMERCIAL LIABILITY
GENERAL LIABILITY LIMITS
Liability
Combined Single Limit $1, 000 , 000 per occurrence
Coverages;
Owners, __Landlords , &"Tenants
•
28
•
GENERAL LIABILITY LIMITS
New York Auto Ins. Plan 68BAP293J660587 04/21/87 - 04/21/88
Commercial Auto
BUSINESS AUTO LIMITS DEDUCTIBLE
Liability
Combined single limit $500, 000
Personal Injury Prot $50, 000 $0
Uninsured Motorists $10, 000/20, 000
ENDORSEMENTS:
Installments
•
•
29
•
LOSS INFORMATION
The loss information is in a separate envelope due to the
size of the loss runs from the CNA Insurance Company.
Your attention is directed to aliability claim of 7/12/85
• Charles Foster loss insured of $2828. This occurred on
Mattituck Park Property and should be eliminated, and the
carrier has been so advised.
The automobile experience covers the period of 12/28/83
to 7/1/87 and the general liability from 1/1/85 to 7/1/87
in the CNA Insurance Company. Note that the prior year coverage
was provided by the Utica Mutual Insurance Company.
•
30
• P R E M I U M Q U O T A T I O N
(To be submitted in duplicate)
A. Buiding and Contents
Deductible All:':Ri.sk Annual Cost
$1,.000
Carrier:
Policy Period:
Premium Payment Plan:
Comments:
B. Extra Expense
Deductible All Risk Annual Cost
• $1, 000
Carrier:
Policy Period:
Premium Payment Plan:
Comments:
C. Boiler and Machinery
Deductible
$5, 000
Carrier:
Policy Period:
Premium Payment Plan:
Comments:
•
! 1
•
D. Valuable Papers
• Deductible
$1, 000
Carrier:
Policy Period:
Premium Payment Plan:
Comments:
E. Comprehensive General Liability
(a) First dollar coverage: $500, 000 or $1, 000, 000
Rating basis:
Carrier:
Premium Payment Plan:
Comments:
•
F. Automobile Insurance
Limits - (a) $500, 000 or $1, 000 , 000
Rate per vehicle:
Carrier:
Policy Period:
Premium Payment Plan:
G. Contractors Equipment Floater
Deductible Rate per 100 Exposure
$1, 000
Carrier:
Policy Period:
•
• T
02
• Premium Payment Plan:
Comments:
H. Umbrella Liablity
$1, 000, 000 - $2, 000, 000 - $3, 000 , 000 - $4, 000, 000 - $5, 000, 000
Rating basis:
Carrier:
Policy Period:
Premium Payment Plan:
Comments:
• I. Police Professional Liability
Premuim:
Carrier:
Policy Period:
Comments:
J. Public Employee Blanket Bond and Crime
Premium:
Carrier:
Policy Period:
Comments:
•
�4
PREMIUM QUOTATION SUMMARY
Total annual.:cost of all coverages with deductibles;
the property coverage including Boiler and Machinery.
$1, 000 Deductible:
$5, 000 Deductible:
Name of Agent/Broker
Street or P.O. Box
City, State, and Zip
• Name of Person Completing Quotation
_Signature
Title
Date:
•
Town of Southold
Claim Listing
POLICE VEHICLES LIABILITY
12/18/86 Barney Harris Struck parked vehicle
9/5/86 Chief Winters Struck other vehicle PD $ 598.77
in rear PI in suit
(Rose Nobile asking $250,000)
POLICE PROFESSIONAL LIABILITY
2/3/85 Ronald Diachun False arrest, assault
7/4/85 Robert Boyle Negligence of waterways
8/3/85 Sandra & Richard Zatarain Police brutality
10/l/85 Est. Jack Leverett Negligence of detour
barricades
3/24/86 Terry Smith Unlawful arrest, assault
6/1/86 Michael Sanford Negligence during time in detention
6/10/86 Jody Adams ?
4/23/87 Donald B. Brown Negligence in injury treatment
PUBLIC OFFICIALS LIABILITY
7/4/85 Robert Boyle Negligence
11/22/85 Lewis Edson Malicious prosecution
12/14/85 LoStack Breach of Contract Denied/Exclusion #10
4/10/86 Harold & Esther Wohl Zoning Article 78
5/21/86 Pindar Vineyards Building Dept Article 78
6/18/86 Kathleen Varano Zoning Article 78
11/25/86 Salvatore Crimi Discrimination in
(Police Dept) employment
PROG CD3905ALC1 ** U N I - C I M S ** REPORT 09/05/dAt
RUN --4 • UTILA,NA FIONAL URANCE GROUP
TIMI 22:U7:54 PAGE...... b
POLICY INpUIRY - REGUES7 FOR PRINT
REQUESTED bY:
PERSON C BURKE
OFF NYMRO
DEPT MARKETING
NAME TOWN OF SOUIHOLO
POLICY NUMBER 0,2!672-7
POLICY eaF UT C1/r2
LOSS PtRIOU 01/01/82 fHRU GI/01/85
LINE/AGNT/CD *-Y2229-2
0
CLAIM CLASS DRIVER ACCIDI-Nf ALCIDENT PAID TO DATE /
OFF NUM - LINE CLAIMANI MO DA YR DESCRIPTION INCURRED LOSS EXPENSE F
D1 40618535 11/23/83 FALLING OR FLYING DEJECT
5221 ALEKSANOEKt IUB'►_"RT !{/41iC1`ttb'_J,t iLk[c1Ci> ftCi - �1:_,l' �t i :_. _�; �rC:»z�L' cC::: � C� F
CLAIM TOTAL
P
() 9 5 MA kA t k PERSONAL INJURY - FALSE A REST SLAN
D1 4.61. 0 12/0b/83 LP CTIL U E L e
( ',f
1 500 0
6212 ADAMS JOUY � , s p
r rY A
c.Q_e_t, _�rt`;� -t 3--LQ(S t't d:t!'ri, �Lt.l�., t.�c.<
a 1 CLAIM TOTAL 1+500
D1 4Q5Z0@95 ul/U7/8.4 ROADWAY OR PARKING LOT LUNOITION
5221 WINDSWAY 6LDG.COXP (6cir:.2 ,`GCE:. 79 79 F
CLAIM TOTAL 79 79
D1 40861449 02/08/84 FALL OUTSIDE BUILDING+ SAME LEVEL
5211 KiITHMAN, kufH CLac,Il�. t tt��-�C✓ !' y CCLc �: fes. .')! ��tt�z!'!� 64.10 6;p.0 F
CLAIM TOTAL 600 biro
D1 4CB61451 11/2x/83 UNCLASSIFItU
,cttt� cad Z
. nsuc � . c �Ccrl . 17f50) ;fa /�Y/6221 LUYSTER, EMILY E,Vf
494 U
CLAIM 7UTAL 17,500 494
D1 4Ce62b4� 01/27/84 CONUlTION OF PREMISES EXTtRIUR
Tat!!n•.lneu�n�l��J read nxte�!t rit, tui t 1e:r :�;• rent tom!
0221 KOHL,GEORGt r A t T `� ' n4 l�( 197 197 F
'cKv:
PROG 6 Lu1
s* U N I — C L A I M S ** REPORT 09/05/84
09/05/ .
RUN 09/U5/ti4 01ICA NAIlUNAI INSJRANCE GROUP
,,` • TIME 2'2:07:54 PAGE...... 9 ''.
POLICY INQUIRY — REQUEST FOR PRINT
(
REQUESTED 6Y:
PERSON S BURKE C
OFF NYMkO
DEPT MARKETING
NAME TOWN OF SOUTHOLD
POLICY NUMBER 022672-7
POLICY EFF DT 01/82
f LOSS PERIOD 01/01/82 THRU 71/01/85
j
LINE/AGNT/CO *—Y2229-2
0 t
CLAIM CLASS DRIVER ACCIDENT ACCIDENT PAID TO DATE /
OFF NUM LINE CLAIMANT MO UA YR DESCRIPTION INCURRED LOSS EXPENSE F
D1 40887122 03/29/84 FALLING Ok FLYING OBJECT
6221 TAMOSUINAS,U.6 L. f�ua'•' -T e'te"u-" ��! IW-""<f !� /Vy - !9E//u>t� . c?k Lc'f 1,267 !-o FAy�� 0
a(f;Irin' )nlc'iv {�
CLAIM TOTAL 1,267
t�5/21/84 IMPROPER DIRECTION OR.SUPERVISION BY INSURED
D1 40866183
rr/L: _/ _�ft'al C:6=✓tr 0.uLc%d ,irr JIIr�Z?i[tCk n<�;rr�cd "/ojfv u.G1 ,CwL cx ft )et 25 �
b221 CILHANOWICZ,F.A. �UtE�F"Ul�/cicCc�A(/J7trcclud rti ctcc%�,� 9rc1 �f!L�dC�['�.J/�lcu"r a"Vv 800 0p ! r1 O
CLAIM TOTAL 800
D1 40868996 04/lb/84 FALL OUTSIDE BUILDING, SAME LEVEL !
6211 WALOSKI,JOSEPHINF. /�pc2'a T„„ t» X`G
olLw tr- m `t``/-,a, � �?1R�c![c/1 104 - lli4 F
CLAIM TOTAL 104 104
D1 40871309 Oo/28/84 ROADWAY _OR PARKING LOT CONDITION
Cl�oJnar/ �`a ,�t /amuC (,n.
a .clt.`r a, /L :ertF�.'rel N 4�d 19000 i D i
6211 WATANABE, YASUSHI. Qq a IGLGvvtl'? ,. ek-t .-bt0- 71Ltc-;^�q� a }Af t f , ,;cyq
C '13t:cY<{f /i�Q.�c
CLAIM TOTAL 1r 0UU Nd /
6/lcfnZuaf A"ad ke cam.-jr,E pt,�
D1 40e730b5 (,8/01/84 CONDITION OF PREMISES — EXTERIOR
8221 GULL POND i�rZtl, ✓,l- .C!;�ir.Gr�.� .�-CL:!`l Ccrc c�`�r"��/EdG✓Jt� l�?L'h rJ1FF2ct��rTi LCc'Ce( �C�7 ��f01/1"
e��
�J12, la t.Ff t 1( .c :1 1-wic't { c. e/ 7; �'K 1/1" f
f ,CJ �b Z[kf 'CLAIM TOTAL Y1vnu f
I N;�U IRY TOTAL 115,872 279555 8,158
TOTAL CLAIMS FOk THIS INQUIRY = 33 t
167#9L SLAMS' �ntD ol -,fl S
. f
_
t
t '
� I
ti
TIME 19.02.32
POLICY EXPERIENCE REPORT , OATS 07/20/$7
`1
REOUESTii R-WILSON PAGE . 1
POLICY NUMBER 002027573 POLICY YEAR 1987 INSURED SCUTHOLD,TOWN CONSOLIDATED AGT. 015115 -
: -- REN. OF EFF_ DATE EXP DATE EVL DATE RUN DATE PRPT ACCOUNT NO AGENT BRANCH 6
2027573 01-01-87 01-01-88 07-01-87 07-01-87 4011 NCT IN USE AA 015115STYPE 6 SONS 1 730 MELVILLE
PRNT BI LMT PD LMT AUDIT EST-RPM M W/C G/L A/L APD I/N PRP BRP OTH MD C W/C G/L A/L APD I/M PRP BUR OTH
ANN# 0500 066108 091 044 20
PREMIUM AND LOSS SUMMARY ###***
„ - LINE A/S DEP/PREM AUU PREM STD/EARN PRE RET AUJ/DIV PD PAID LOSSES PAID RESERVES TOTAL INC L/R
34 A 40,551 20,295 0 179106 272 30,220 47,588 234.5
35 A 22961t> 110308 0 19736 1.736 15.4
_ AUTO T 63#207 - 3. 1 #603 0 180842 272 300210 499324 156.1
36 A 69194
3.097 p
37 A 10#055 5.027 0 39156 68 30224 64*1
PHY U T 16.249 80124 0 3.156 68 39224 39.7
GRAND TO 799456 39,727 0 211998 340 309210 529548 132.3
Cca f% smAges,"&�
) *#*#*#** CLA AIL ##*#*#4*
LLAIM Ntl ACC-DT CLAIMANT NAME ML SLJ, PAID LOSSES PAID EXP RESERVES TOTAL INC
008938 97 31-271028-01 012287 vkASSO SONIA J1 4 35 1 110239.25 125.00 6, 169 17.9533.29
8888 97 31-271028-02 012287 EPITY ALEXANDRIA 31 34 35 1 2,987.21 20103 50090.21
8883 97 31-271028-u3 U12287 EPITY THEODORE 31 34 35 1 2#644.32 2944E 50090.32
8888 97 31-271028-04 012287 KISPERT CLARA 31 34 35 1 60.00
" 60.00
3C ...._ 8883 <07 31-271028-05 1112287 GLENNON ANN 31 34 35 1 60.00 60.00
8888 97 31-271028-06 U12287 LILCL' 31 35 35 1 CWP
8888 97 31-271028-07 012287 6CNKCSKI MARY 31 34 35 1 60.00 60.00
r_ 8888 97 31-271028-08 012237 EPITY ALEXANDRIA 31 34 35 1 5,090 50090.00
8888 97 31-271028-09 012237 EPITY THEODORE: 31 34 35 1 59090 50090.00
8886 97 31-271028-10 0:12287 GRASSO SONIA 31 34 35 1 147.25 99312 99459.25
36 ..-------------__-..__ .._8888.-_97 31-271028-11 012267 NCVIT CHARLES ' 31 34 35 1 55.00 55.00
f IV LOST CONTROL ON ICE STRIKING POLE
V,8888 97 31-271525-00 012787-FERRIS JOAN 8 31 35 33 1 19127. 14 19127.1,4
VEH 1 VEH 2 COLLIDED
X8888 97 31-271507-00 012987-GREENPORT VILLAGE O 31 35 33 1 CWP
IVSD VEH SAC-KED INTO PARKED CLMT VEP
V8888 97 00--25944-33• 022387 GEORGE CCNWAV 31 35 33 1 608.57 608.57
IV HIT OV
TOTAL ALL 3 LOSSES Qt 179105.82 272.25 309210 479588.07
as �• TOTAL ALL 3 LOSSES Qa 1 ,735.71 .00 1 0735.71
ACCIDENT
6a CCDNT
--
TOTAL ALL A�..tl_ LOSSES 180842.53 272.25 309210 499323.78
j
l./
X 8888 97 31-271028-0-0 012287 SOUTHOLD TOWN OF 31 37 35 1 39155.66 67050 39223.16
2v LOST CONTROL ON ICE STRIKING POLE
si TOTAL ALL 36• LOSSES (611 .00 .00
,� -- -- _
TOTAL ALL 37 LOSSES to`
TOTAL ALL � LOSSES _
30155.66 67.50 3,223.16
�. 3#155.66 67.50 3,223.16
s• _ACC.I_DENT COUNT - 1-`��----
1,7
GRAND TOTAL ALL 219997.19 339.75 30,210 52,546.94
I
60
63
St
C NA TNell i0aNrF
7 11 jL,
L..A INSURANCE TIME 19e02s32
POLICY EXPERIENCE REPORT DATE 07/20/87
4 PAGE 2
REQUESTOR-WILSON
POLICY NUMBER 002027573 POLICY YEAR 1986 INSURED SCUTHCLD*TOWN CONSOLIDATED AGTa 015115
10
REN* OF EFF CATE EXP DATE EVL CATE RUN DATE PRPT ACCOUNT NO AGENT BRANCH
2027573 01-01-86 01-01-87 07-01-87 07-01-87 401.1 NOT IN USE AA 015115STYPE 6 SONS 1 730 MELVILLE
PRNT 01 LAT PD LMT AUDIT EST-RPM M W/C G/L A/L APO I/M PRP BRP OTH 40 C W/C G/L A/L APO I/P PAP SUR GTH
ANNI 059 20 ---- --
PREMIUM AND LOSS SUMMARY
LINE A/S DEP/PREM aUo PREM STO/EARN PRE RET AOJ/OI.V PO PAID LOSSES PAID RESERVES ICTAL INC L/R 20
34 30,427 2#276- 28s151 0
35 16*662 192bl- 15*401 0 69181 376 6*557 42.6 22
AUTO T 479J89 39537- 43*552 0 69181 376 69557 15*1 24
36 59373 157- 59716 0 691 691 12e1
r 37 90919 2ae- 9*631 0 109506 337 10,843 112*6
- 0 337 119534 75*2 79
PHY D, T 15s792 445 15*347 11 *197
GRAND TO 629881 3*962- 589899 0 179378 713 18,091 30e7
30
CLAIM DETAIL
32
LOCN PS CLAIM NO ACC-OT CLAIMANT NAME AS ML SL PAID LOSSES PAID EXP RESERVES TOTAL, INC
Y8883 97 31-254016-00 010886 GOLDSMITH 31 35 33 1 991*73 60e50 1 *052*23 4
ANDREW C INSD VLH CCLLIDED WITH CLMT VEH
)�aaad_ -9.7 31-260005-00 020830 MUSHERS SCOTT 31 35 33 1 292*40 bs000 360*40
ZIGMUND HEINSO ShCWPLCW STRUCK PARKED CLMT VEH
8888 97 31-2t0098-00 022586 TUTH ILL JtFFREY 31 35 33 1 64#50 64*50
PAUL EDCLAT STRUCK INSD VEH
18888 97 31-263980-00 042286 LILCC 31 35 33 1 150*00 150*00
JAMES R CLMT TUCK DOWN POWER LINES k Q7
81363 97 31-262541-00 06108b WINTER HARBOR FISHE J1 35 33 1 243.54 243o54
J 8HCLMT VLH WINCShIELD DAMAGED BY RCCK FALLING OFF INS
4088.38 97 31-2ib3571-OC 010186 GENT ALICE 31 35 33 1 1,494*80 54*25 19549o05
VEH 1 BACKEC INTC VEH 2 WHICH WAS PARKED
4,3888 97 31-263422-00 V71666 RUTKCW CARROLL 31 35 33 1 1 ,201 *32 54*76 1 ,256.0e
THUMAS WETREE LIMB FELL OFF INSD VEH STRUCK CLMT VEH
8888 97 31-2t5244-01 090586 MOBILE ROSE 31 35 39 1 CUP
CAN W INSD VEH STRUCK CLMT VEH
8888 97 31-218559-01 112036 ZLATNISKI MARK A 31 35 33 1 352 .29 74* 17 426.46
Y,8888 97 31-208559-02 112J36 CRENSHAW CALVIN 31 34 33 1 CWP
CALVIN C INSD VEH HIT CLMT VEH
8888 97 31-268916-00 112180 MEDGETTE ERNST L JI 35 33 1. 1 *213e01 19213*01
CRAIG G INSO VEH HIT CLMT VEH
TOTAL ALL 34 LCSSES e0o soo
TOTAL ALL 35 LOSSES 5*939*09 376*18 69315*27
TOTAL ALL AUTO LCSSES 59939*09 376. 18 6*315e27
ACCIDENT COUNT to to
8888 97 00--25277-67 0324ab INSD 31 37 39 1 87.50 87*50
.8888 97 00--25277-68 032486 INSD 31 37 39 1 345*85 345*85
POLICE IN PURSUIT STRUCK INTENTICNALLY BY OTHER VEH
X-6888 97 00--25277-73 042186 SUUTI-OLD' TCWN POLIC 31 37 33 1 187*43 187*43
IV HIT GV
--25277-75 042986 SGUTHOLD TOWN FOLIC 31 36 33 1 690*79
690*79
)P3888 97 00 76
IV MIT DEER
)IL 8888 97 31-265244-00 090586 SCUTHOLD TOWN OF 31 37 39 1 2,844*97 99*50 2*944*47 78
- DAN W INSD VEH STRUCK CLMT VEH ------- 80
82
4 4w
184
q
} CNA INSURANCE
POLICY EXPERIENCE REPORT TIME .19.02.32
DATE 07/20/87 i!
REQUESTOR—WILSON PAGE 3
r I
POLICY NUMBER 002027573 POLICY- YEAR 1986 INSURED SGUTHOLD•TOWN CONSOLIOATEO AGt. 015115-
_
_
CLAIM DETAIL
LOCN PS CLAIM NO ACC—DT CLAIMANT NAME AS ML SL * PAID LOSSES PAID EXP RESERVES TOTAL INC
X'8888 97 31-26X3559-00 112086 SOUTHOLD TOWN OF 31 37. 33 1 9.605.00 237.25
9.842.25
8888 97 31-268559-80 112086 SALVAGE/SUBROGATION 31 37 33 1 2.565.00—
- --- _
' CALVIN CNINSO VEH HIT CLMt VEH
—2.56 5.00
TOTAL- ALL 36 LOSSES 79
.
0 6!0
TOTAL ALL 37 LOSSES 690.79 .0. -
10.505.75 336.75 10.842.50
TOTAL ALL PHY D LOSSES 11 .196.54 336.75
ACC IDENT_COUNT 5 1 l•533.29
97 OU--25277-59 022186 MATTITUCK GLASS M 31 35 33 1 241 .88 241.88
31 _ STCNE BQCKE WINDOW
TOTAL ALL 34 LCSSE; •00 .00
TOTAL ALL 35 LCSSES 241 .88 .00 241 .88
24 TOTAL ALL AUTO LOSSES- _ 241 .88 .00 241.88
ACCIDENT COUNT 1
n GRAND 16
TOTAL ALL
�__.-- -- - 17.377.51 712.93
-_ 18.090.44
30
33
86
31
43
_
45
J f
48
S4 y
60
61 6
46
i
d
t
�i
— s
CNA INSURANCE TIME 19.02.32
POLICY EXPERIENCE REPORT DATE 07/20/87
PAGE
REOUESTUR-WILSON
PCLICY NUMBER 002027573 POLICY YEAR 1985 INSURED SCUTHOLD•TOWN CONSOLIDATED AGT. 015115
REN. OF EFF DATE EXP DATE EVL DATE RUN DATE PRPTACCOUNT NO AGENT BRANCH
2027573 01-01-85 01-01-86 07-01-87 07-01-87 4011 NOT IN USE 015115STYPE 6 SONS 1730 MELVILLE
C PRNT BI LMT PD LMT AUDIT EST-RPM M W/C G/L A/L APD I/k PRP BRP OTH MO C W/C G/L A/L APD I/M PRP $UR OTH
ANN'_-------0500 0500_ FINAL_ 042508 -- 057 058 20
#***** PREMIUM AND LOSS SUMMARY ##*###
LINE A/S DEP/PkEM AUD PREM STD/EARN PRE RET A 7J/DIV PO PAID L05SES PAID RESERVES TOTAL INC L/R
34 * 19.945 287 20.232 0 159000 33 15.033 74 .3
f 35 * 10.984 105 119089 0 1 .807 165 1 .972 17.8
AUTO T 30.929 392 319321 0 16.807 198 17.005 54.3
36 A 4958 49558 0
c.
37 A 8,215 8.215 0 57 57 •7
PNY ------T-_--I2.773 ------ --- 129773 0 57 57
GRAND TO 439702 392- 44.094 0 16.807 255 17.062 38.7
CLAIM DETAIL ***##***
LUCN PS CLAIM NO ACC-DT CLAIMANT NAME AS ML SL * PAID LOSSES PAID EXP RESERVES TOTAL INC
i,
Y18888 97 31-249999-00 013185 6AR2AC GEORGE 31 35 33 1 19321.48 50.Ofl 1 .371.48
CRAIG GBCLMT VEH SKID COLLIDED WITH INSD VEH
v 888.3 9T 31-251501-0 1 041 785 KOCH EL1 ZA8ETH 31 35 33 - 1 65.00 65.00
X8888 97 31-251501-02 041785 KLIFP JASON 31 34 33 1 Clip j
K88- 8 97 31-251501-03 041785 KOCH ELIZABETH 31 34 33 1 15.000.00 32.50 15.032.50
JASON KLVr_H 2 CRCSSED IN FRONT OF VEH 1 CAUSING COLLISI
X8888 97 31-253124-OC 070165 LEE JOHN 31 35 33 1 264.58 50.00 314.58
„ CHESTER SNINSD VEH BACKING UP STRUCK CLMT VEH
8888 97 31-2519141-00 122385 BLASKO L 31 35 33 1 220*63 220.63
CLMT ALLEGES ROCK FELL UFF INSD VEH SRGKE WINDSHIELD
TOTAL ALL 34 LOSSES 15. 000.00 32.50 15.032.50
TOTAL ALL 35 LCSSES 19806.69 165.00 1 .971.65
s.. TOTAL ALL AUTO LOSSES 16,806.69 197.50 17.004. 19
ACCIDENT COUNT 4
')(8888 yT 31-251501-00 0417135 SCUTHOLD TOWN OF 31 37 33 1 438.45 56.50 494.95
X8888 97 31-251501-80 041785 SALVAGC/SUOROGATION 31 37 33 1 438.45— —438.45
JASON KSVEH 2 CRCSSED IN FRONT OF VEH 1 CAUSING COLLISI
i T'JTAL ALL 36 LOSSES •00 •00
TOTAL ALL 37 LOSSES .00 56.50 56.50
TOTAL ALL PHY D LOSSES .00 56.50 56.50
ACCIDENT COUNT 1
GRAND TOTAL ALL 5 16.806.69 254.00 17. 060.69 j
e
i �.
— T IME 19.02.32 3i s
CNA INSURANCE
• - • POLICY EXPERIENCE REPORT DATE 07/20/87 4.
PAGE 5 '
REOUESTOR—WILSON
POLICY NUMBER 002027573 POLICY YEAR 1984 INSURED SOUTHOI.U•70WN CONSOLIDATED AGT. 015115 `
�° �_— -------_---- REN. OF -_---EPF__C. AT-E -EXP-DATE _EVL- DATE_RUN DATE PRPT ACCOUNT NO_ AGENT BRANCH -
2027573 12-28-84 01-01-85 07-01-87 07-01-87 4011 NCT IN USE T 015115STYPE E SONS 1 730
PRNT 01 LMT PO LMT AUDIT EST—RPM M W/C G/L .A/L APD I/M PRP BRP OTH Mill C W/C G/L A/L APD I/M PRP 8UR 13TH
ANN'------- 0500--- -- 0500L- - - _ t700.0fa0 _. _ 058 20
PREMIUM ANU LOSS SUMMARY *##***
A/S_ DEP/P ERI----- AUD_PREM-STD/EARN_PRE RET ADJ/DIV. PO PAID LOSSES . _ PAID_ RESERVES TOTAL INC L/R
37 A 5 5 0
GRAND TO 5 5 0
21
2+ ---
27
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36
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39
42
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7 CNA INSURANCE i
TIME 19.02.32
s POLICY EXPERIENCE REPORT DATE 07/20/87
' PAGE 6
s ` FLOUESTOR-WILSON
b
POLICY NUMBER 002027573 POLICY YEAR 1983 _ _ .--_-----__- - -
t INSURED SOUTHOLD9TOMN CONSOLIDATED AGT. 015115 �?
,ro
+ REN. OF EFF DATE EXP DATE EVL DATE RUN DATE __- PRPT ACCOUNT NO AGENT BRANCH
2027573 12-28-83 12-28-84 07-01-87 07-01-87 4011 NOT IN USE 015115STYPE b SONS I 730 MELVILLE
PRNT 8I LMT RO LMT AUDIT EST-RPM M W/C G/L A/L APD I/M PRP BRP OTH MD C W/C G/L A/L APO I/M PRP BUR OTH "
,2 __ ANN' 0500 ---0-50-0---FINAL 022212 062 067 20 ,
#***#* PREMIUM AND LOSS SUMMARY
AUD PREM STD/EARN PRE RET ADJ/DIV PD PAID LOSSES PAID RESERVES TOTAL INC _ _ L/R _
- --
_ 34 * 14 .289 735 15.024 p
35 * 79799 355 89154 0 736 736 9.0 "`
AUTV __j________22 9-088 1. 090 23.178 0 736 - 736 3.2
36 A 3. 712 39712 0 443 443 11 .9
37 A 7.465 7.465 0 4 4 *1
si __PHY 0 T 1 1 •177 11 9177 p 443 4 447 4.0
GRAND TO 33.265 1 •U90 34.355 0 1 . 179 4 19183 3.4
CLAIM DETAIL #**#****
LOCM P5 CLAIM NO AGC-!7T CLAIMANT NAME AS ML SL * PAID LOSSES PAID EXP RESERVES TOTAL INC
88dS 97 00--23186-61 021784 NELSON E BEEaE 31 35 39 1 112.61 112.61
2 PARKED 1 BACKED UP AND STRUCK 2
8888 97 00--2318b-56 030984 HENRY SANTACROCE JI 35 33 1 249.09
249.09
STuNE FLEW OFF TRUCK STRUCK CLMT WINDSHIELD CRACKING
88.38 97 31-242909-01 030934 CONNOLLY MICHAEL 31 35 33 L 202.60 202.60
PAUL G INSD VEH SKID ON SNOW COLLIDED WITH CLMT VEH
8888 97 00--44040-80 042584 MARK M KILKENNY 31 35 39 1 171 .60 171.60
1 RAN INTO 2
8888 97 31-25UIOS-00 112134 ANDREW6 VALERIE 31 35 33 1 CWP
STONE FL£* UP FROM INSD VEH CRACKED CLMT VEH
}
- _ TOTAL ALL 34 LOSSES .00 .00
TOTAL ALL 35 LOSSES 735.90 .00 735.90
TOTAL ALL AUTO LOSSES 735.90 .00 735.90
ACCIVENT COUNT 5
8883 97 31-244909-00 030984 TGWN OF SOUTHCLO 31 37 33 1 3.50 3.50 �
PAUL G INSD VEH SKID ON SNOW CGLLIDED WITH CLMT VEH
-.
88813 97 00--24152-34 111284 SUUTHOLD TOWN P'=3LIC 31 36 39 1 442.69 442.69
VEH 1 HIT UEiER s
TOTAL ALL 36 LOSSES 442.69 .00 442.69
TOTAL ALL 37 LOSSES .00 3.50 3.50
TOTAL ALL PHY O LOSSES 442.69 3.50 446.19
62
4 .v
ACCIDENT COUNT 2
- _ id ,',
GRAND TOTAL ALL 7 19178.59 3.50 1 . 182.09 ebt-
72
is
S. 64
-- _
34
I
2 NA INSURANCE
TIME 19*02*32
3 POLICY EXPERIENCE REPORT DATE 07/20/e7
PAGE
REQUESTOR—WILSON
PLLICY NUMBER 002394469 POLICY YEAR l9e7 INSURED SOUTHOLD*TOWN CONSOLIDATED AGT* 015115
REN* OF EFF DATE EXP DATE EVL DATE RUN DATE PRPT ACCOUNT NO AGENT BRANCH
NEW t)1-u1-87 11-01-88 07-01-87 06-29-37 5931 NOT IN USE KA 015115STYPE & SONS 1 730 MELVILLE
PRNT 81 LMT PD LMT AUDIT EST—RPM M w/C G/L A/L APO IIM PRP BRP GTH 90 C W/C G/L A/L APD I/M PRP BUR CTH
12 ANN' 0500 05c0 090076 042 042 20
PREMIUM AND LOSS SUMMARY
15 _-L I NEI A/S- DEP/.P-REM ------,-AUD--P-REM STD/EARN PRE RET ADJ/DIV po PAID LOSSES PA ID RESERVES TOTAL INC L/R
32 0 8.077 89077
33 0 332 4.156 40488 22
0 332
129233 129565 24
62 A 4.26 i— 29130— 0
GRAND T 29130— 0 332 129233 12956!5
21
CLAIM DETAIL
LOCH Ps CLAIM NO ACC—DT CLAIMANT NAME AS ML SL * PAID LOSSES PAID EXP RESERVES TOTAL INC
24 888.397 31-272109-00 010887 NY TELEPHONE 85 31 33 35 1 -7 49156 49156*00
INSO INSTALLING DRAIN BROKE TELEPHONE CABLE
X8888 97 31-274004—OC U40387 PECONIC CESSPOOL 85 31 33 35 1 155*70 155*70
-7 INSD ALLECES DAMAGES
A 8888 97 31--- 274499-00 041187 STEINACHER ANN 81 31 .32 31 1 89 077 89077*00
CLMT TRIPPED
TOTAL ALL 32, LCSSES sou O00 89077 89077*00
TOTAL ALL .33 LOSSES 155.70 000 4*156 49311o70
TOTAL ALL LIAR LCSSES 155s70 *00 12*233
at
ACCIDENT COUNT - 12*388*70
97 00--25944-32 012087 JOSEPH MCCARTHY 85 31 33 35 1 17605146
PROPERTY CAMAGE 176o5l
TOTAL ALL 32 LOSSES
000 000
TOTAL ALL -33 LOSSES 176*51 000 176*51
TOTAL ALL LIAB LOSSES 176*51 goo 17E.51
ACCIDENT CUUNT
GRAND TOTAL ALL 4 3.32*21 000 129233 12*565*21
43
14
70
76
73
60
CNA INSURANCE T 184t •02-.32__.�
POLICY EXPERIENCE REPORT DATE 07/20/87 k;
PAGE - 2
REQUESTOR—WILSON
i
POLICY NUMBER 002394469 POLICY YEAR 1986 INSURED SOUTHOLD•TOWN CONSOLIDATED AGT. 015115
•
REN* OF EFF-_DATE -EXP DATE_ EVL GATE RUN DATE ._ PRPT _ACCOUNT NO AGENT BRANCH _
NEW 01 -U1-8b 01-01-87 07-01-87 06-29-87 5931 NOT IN USE KA 015115STYPE E SONS I 730 MELVILLE
PRNT HI LMT PU LMT AUDIT EST-RPM M W/C G/L A/L APD I/M PRP BRP OTH MD C W/C G/L A/L APD I/M PRP OUR DTH l
12 ANN• USOJ 0500 FINAL 090076 042 - - 042 042 042 20 _
PREMIUM AND LOSS SUMMARY
Is -__,__._LINE,_-_Af5_DEP/PREM-----_. AUD PREM -STD/EARN PRE RET ADJ/DIV _PD PAID LOSSES PAID RESERVES TOTAL INC L/R
32 * 1009774 59809 106.583 0 19700 1 .700 1.6
33 * 45.818 2.518 48*336 0
154.919 0.-- 1 .700 _ 1 .700 1. 1 _
--------v - 53 A 20. 100 209100 0
x fit A 20,912 20.912 0
21 ;--- --._.___.... _ 86 _ A-.--- 169_ -- -----. 169 .- 0- -
GRAND T 1879773 8.327 19b,100 0 19700 1 ,700 .9
:4 #**** ** CLAIM DETA IL *******#
LUCK `PS CLAIM NU AGC-UT CLAIMANT NAME AS ML SL * PAID LOSSES PAID EXP RESERVES TOTAL INC
8888 97 31-259445-00 01108b KLIFF JASON 85 31 33 35 1 CNP
CLMT VEH PARKED IN TOWN PARKING LOT FOUND WINDOW
?�[
VB888 97 31-262139-00 041786 KING MARION R 81 31 32 31 1 1 ,360.00 jr 77,c) 19360.00
CLMT ALLELES INJURIES DUE TO FALLING IN PGTHCLE
3^ _ ( 8888 97 31-267664-00 081286 MOELIUS SANDRA 81 31 32 31 1 340.00 340.00
CLMT TRIPPED*FELL
8888 97 1-265071-00 082286 SMITE THOMAS 61 31 32 31 1 �= CWP
CLMT CVERTUkNED CN TRIKE
X8888 97 31-267470-00 101686 ZUHCEK1 SHF_ ILA 85 31 33 35 1 CWP
CLMT HIT MUFFLER LYINL IN ROAD(Z(.S.51)
3:
TOTAL ALL 32 LOSSES _ _ _ 1 •700.00 .00 19700000
_ ..
TOTAL ALL 33 LOSSES .00 .00 .00
j TOTAL ALL LIAR LOSSES 1 .700.00 .00 19700.00
ACCIDENT CL;UNT 5
i
" GRAND TOTAL ALL 5 1 .700.00 .00 19700.00
„ t
46
54
s
61
3
TIME 19*02*32
"A INSURANCE
POLICY EXPERIENCE REPORT DATE 07/20/87
PAGE 3.
REQUESTUR—WILSON
POLICY NUMBER 002394469 POLICY YEAR 1985 INSURED SOUTHGLD*TOWN CONSOLIDATED AGT* 015115
REN-*--,G-F----,--E.FF-.DAT-E-.-.EXP-.-DA-TE--E-VL-. CATE—RUN DATE _'..__ 'PRP�T ACCOUNT NO
NEW 01-01-85 01-01-86 07-01-87 06-29-87 5931 NOT IN USE KA 015115STYPE & SONS 1 730 MELVILLE
PRNT 81 LMT PO LMT AUDIT EST—RPM M W/C G/L A/L APO x/m PRP BRP OTH MD C W/C. G/L A/L APO I/M PRP BUR 0TH
12 -ANN! _042.--042_.0.42._.20.
PREMIUM AND LOSS SUMMARY
15 LINE A/S DEP/PREM AUD PREM STD/EARN PRE RET AOJ/DIV PD PAID LOSSES PAID, RESERVES TOTAL INC L/R zo
32 # 519260 49324— 46*436 0 344 4*299 83.020 e7*663 188*8
C
33 27, 179 210460 2910639 0 310993 93 49086 13o8 22
LIAB T 789439 2#364— 76ip075 0 49337 __. _..--_._49392_.___839020 919749 120*6 24
53 A 410501 49501 0
62 A 710334 7.834 0 26
86 A Lis 118 0 23
GRAND T 9010892 29364— 88,528 04*337 49392 83.020 91 *749 103*6
30
CLAIM DETAIL 32
LOCN PS CLAIM NO ACC—DT CLAIMANT NAME AS ML SL *. PAID LOSSES PAID EXP` RESERVES TOTAL INC
)1-8888 97 31-259127-00 010285 KREIGER WELL PUMP85 31 33 35 1 19012*00 19012*00 jsa {�
TOWN MOWER DAMAGED 2 GATE VALVES
)0888 97 31-249558-00 011585 COCKERHLLL EDYTHE81 31 32 31 1 55*00 55*00
CLMT TRIPPEC*FELL OVER SLAB OF CEMENT
X3888 97 31-251621-00 012785 WILCENSKI DE8GRAH81 31 32 31 1 1093905519939*55
CLMT ALLEGES INJURY DUE TO NEGLIGENCE OF INSO
hu,
)(8888 97 31-251991-00 020335 DIACHUN RONALD 81 31 32 31 1CWP
CLMT ALLEGES FALSE ARREST*MALICIOUS PROSECUTICN*ASSAULT Prb6 44
)(6888 97 31-250005-00 020685 BORRILL DAVID 85 31 33 35 1 19128902 19128.02
)8888 97 31-250005-00 020685 BORRILL DAVID 85 31 33 35 1 1 ,534.3E 53000 19587*38
EDWARD ANINSD VEH CLEARING SNOW CGLLIDED WITH CLMT VEH
V_8888 97 31-250927-00 031335 GOHIER VIRGINIA 81 31 32 31 1 60S4 CWP
CLMT TRIPPED*FELL ON SIDEWALK
)Q8888 97 31-252244-00 041985 LLOYD MARIE 85 31 33 35 1 95000 95000
CLAT TRIPPED OVER 14AISEC SIDEWALK FELL*SUSTAINED INJURY
;98888 97 31-253982-00 051185 BAINERIDGE KEITH 81 31 32 31 1 1 *235*00 19235.00
CLMT ALLEGES INJURY '_'UE TO NEGLIGENCE CF INSO
)C8883 97 31-253163-00 Obla85 KOSSMANN PATRICIA85 il 33 35 1 3e50 3*50
9,8888 97 31-253163-00 Ub1685 KOSSMANN PATRICIA85 31 33 35 1 36.75 36*75
2 €
8888 97 31-253163-00 061635 KOSSMANN PATRICIA85 31 33 35 t 223*21 223o21
IV STUCK IN FLOOD AREA S2
6_888 8 97 31-254499—OC 070485 BOYLE HOBERT 81 31 32 31 1 759520 759520o00
883 97 31-254499-01 070485 FOYLE ROBERT 81 31 32 31 t CWP
--- -------
t88 97 31-254499-02 070485 BOYLE RICHARD 81 31 32 31 1 CWP
CLMT HAD AMPUTATION OF PART OF LEG DUE TO BOATING ACCID
Y8888 97 31-254311-00 071285 FOSTER CHARLES _ - 81 31 312131 1 328.55 2.500 2.828.55
CLMT WALKED INTO CHARCOAL FIRE PIT
0888 97 31-251750-00 092785 ERICSON A C 85 31 33 35 1 CWP
HURRICANE CAUSED. TOWN TREE TO FALL ON WIRES TO DWELLING
8888 -97 3-1-258766-00 100185 LEVERETT JACK 81 31 32 31 1 795.85 59000 59795985
CLMT DIED AS A RESULT OF CAR ACCIDENT ALLEGES TOWN AT IF
"8888 97 31-258157-00 111485 ROSE ELIZABETH 81 31 32 31 1 289e00 289*00
CLMT ALLEGES SHE TRIPPED ON SIDEWALK
�-8888. 97 31-259694—OU 120285 RAYNOR DAVID 85 31 33 35 1 CWP.
tot
60 CLMT GOT TAR ON VEH FROM NEWLY TARRED ROAD
o3 I
CNA INSURANCEDATE 07/20/87
:v
POLICY EXPERIENCE REPORT ,!
r AGE 4 s
WO ;
'00 REQUESTOR=WILSON
POLICY NUMBER 002394469 POLICY YEAR 1985 INSURED •SOUTHOLD•TQWN CONSOLIDATED AGT. 015115 �
3 *****#*# CLAIM DETAIL €!
LOCN PS CLAIM NO ACC—DT CLAIMANT NAME AS ML SL * PAID LOSSES PAID EXP RESERVES TOTAL INC
1OTAL ALL 32 LOSSES 344.00 49298.95 839020 879662.95
3.g92.b1
_ _ — -- -
_— _ _ -__-_ ___ 93.25 49 085.86
_ -- --_ _
TOTAL ALL 33 LOSSES
- 4.336.b1 43392.20 83.020 913748.81
TOTAL ALL LIAR LOSSES
r ACCIDENT CGUNT.----c - 15 _
8838 97 31-250253-00 020985 SOUTHOLD TOWNSHIP20 31 62 30 1
CWP
CLNT BACKING UP LCIST ST CONTROL STRUCK CEMENT WAL1- 2.
.00 .00
,a TOTAL ALL FIRE LOSSES
4 ACCIDENT COUNT I
i _
- - _
GRAND TOTAL ALL 16 4.336.61 4.392.20 839020 919748.81
1
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36
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42
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51
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SEP 2 3 1W7 TOWN OF SOUTHOLD
PRE-QUALIr ICATION QiJES'1'luNtVt�1xE
See"T~C6&
- Dat
Name of Firm: E-AJC
Servicing Off ice Address
Zip Phone��
1 . Total nur =r of professional staff_
ry (p
Total number of clerical/support staff
2 . Please attach evidence of current insurance agents ' /brokers '
errors and ommissions insurance with a minimum limit of
$1, 000, 000.. per occurrence.
3 . Please attach statement certifying compliance with the
requirements of the Equal Employment Opportunity Acta
(Copy attached)
4 . Is marketing to excess and surplus lines -
(a) Direct -iso
r
(b) Other areas ��u.. S 4A, 1
5 . Please list any special services available (safety, loss
prevention, claims adjustment, EDP claims, reports , etc. ) :
From within Firm From Insurance Companies or Others
6 . How ften will you review claims and serves with Village?
7 . List in order of preference those markets which your
firm would wish to approach for insurance, showing
servicing office ' s current total annual premium volume
for each market.
bility (Aut and General)
It
2) ?� l
operty,
2)
8. Provide any other information about your firm which
might be pertinent to selection.
Na f Person Comp leti g Questionnaire
Signto
Title:
•a
BIDDER: SECTIONS 1 THROUGH 4 ARE PAU OF THIS PROPOSAL
SECTJON 1 . ANTI-DISCRIt,iNATION CLAUSE:
During the performance of this contract, or bid , the contractor
agrees as follows:
(a) The contractor will not discriminate against any eimployee or
applicant for employment because of race, creed, color, sex, or national
origin, and will take affirmative action to insure that they are afforded
equal employment opportunities without discrimination because of race,
creed, color, sex, or national origin. Such action shall be taken with
reference, but not be limited, to: recruitment, employment, job assign-
ment, promotion, upgrading, demotion, transfer, l'ayoff or termination,
rates of pay or other forms of compensation, and selection for training
or retraining, including apprenticeship and on-the-job training.
(b) The contractor will send to each labor union or representative
of workers with which he has or is bound by a collective bargaining or
other agreement or understanding, a notice, to be provided by the State
Commission for Human Rights, advising such labor union or representative
of the contractor's agreement under clauses (a) through (g) (hereinafter
called "non-discrimination clauses") . If the contractor was directed to
do so by the Town as part of the bid or negotiation of this contract, the
contractor shall request such labor union or representative to furnish
him with a written statement that such labor union or representative will
not discriminate because of race, creed, color, sex, or national origin
and that such labor union or representative either will affirmatively co-
operate, within the limits of its legal and contractual authority, in the
• implementation of the policy and provisions of these non-discrimination
clauses or that it consents and agrees that recruitment, employment and
the terms and conditions of employment under this contract shall be in
accordance with the purposes and provisions of these non-discrimination
clauses. If such labor union or representative fails or refuses to com-
ply with such a request that it furnish such a statement, the contractor
shall promptly notify the State Commission for Human Rights of such fail-
ure or refusal .
(c) The contractor will post and keep posted in conspicuous places,
available to employees and applicants for employment, notices to be pro-
vided by the State Commission for Human Rights setting forth the substance
of the provisions of clauses (a) and (b) and such provisions of the State's
laws against discrimination as the State Commission for Human Rights shall
determine.
(d) The contractor will state, in all solicitations or advertisements
for employees placed by or on behalf of the contractor, that all qualified
applicants will be afforded equal employment opportunities without dis-
crimination because of race, creed, color, sex, or national origin.
(e) The contractor will comply with the provisions of Sections 291-
299 of the Executive Law and the Civil Rights Law, will furnish all inform-
ation and reports deemed necessary by the State Commission for Human Rights
under these non-discrimination clauses and such sections of the Executive
Law, and will permit access to his books, records and accounts by the State
Co,mission for Human Rights , the Attorney General and the Industrial Commis-
sioner for purposes of investigation to ascertain compliance with these non-
discrimination clauses and such sections of the Executive Law and Civil
Rights Law.
(a)
M This contract -,ay be forthwith canceled, terminated or suspended,
in whole or in part, by the Town upon the basis of a finding made by the
State Co;z.ission for Human Rights that the contractor has not complied with
these non-discrimination clauses , and the contractor may be declared in-
eligible for future contracts made by or on behalf of the Town, until he
satisfies the State Cc" ission for Human Rights that he has established and
is carrying out a program in conformity with the provisions of these non-
discrimination clauses. Such finding shall be made by the State Commission
for Human Rights after conciliation efforts by the Commission have failed
to achieve compliance with these non-discrimination clauses and after a
verified complaint has been filed with the Commission, notice thereof has
been given to the contractor and an opportunity has been afforded him to
be heard publicly before three members of the Connission. Such sanctions
may be imposed and remedies invoked independently of or in addition to
sanctions and remedies otherwise provided by law.
(g) The contractor will include the provisions of clauses (a) through
(f) in every subcontract or purchase order in such a manner that such pro-
visions will be binding upon each subcontractor or vendor as to operations
to be performed within the State of New York. The contractor will take
such action in enforcing such provisions of such subcontract or purchase
order as the Town may direct, including sanctions or remedies for non-
compliance. If the contractor becomes involved in or is threatened with
litigation with a subcontractor or vendor as a result of such direction
by the contracting agency, the contractor shall promptly so notify the
Attorney .General , requesting him to intervene and protect the interests
of the Town.
SECTION 2. - NON-COLLUSIVE BIDDING CERTIFICATION:
By submission fo this bid, each der an each person signing on
behalf of any bidder certifies, and in the case of a joint bid each party
thereto certifies as to its own organization, under penalty of perjury,
that to the best of his knowledge and belief:
(1) The prices of this bid have been arrived at independently'with-
out collusion, consultation, communication, or agreement, for the purpose
of restricting competition, as to any matter relating to such prices with
any other bidder or with any competitor;
(2) Unless otherwise required by law, the prices which have been
quoted in this bid have not been knowingly disclosed by the bidder and
will not knowingly be disclosed by the bidder prior to opening, directly
or indirectly, to any other bidder or to any competitor;
and (3) No attempt has been made or will be made by the bidder to in-
duce any other person, partnership or corporation to submit or not to sub-
mit a bid for the purpose of restricting competition.
NOTE: Chapter 675 of the Laws of New York for 1966 provides that
every bid made to the Town or any Town department, agency or official there-
of, where competitive bidding is required by statute, rule or regulation,
for work or services performed or to be performed or goods sold or to be
sold, shall contain the foregoing statement subscribed by the bidder and
affirmed by such bidder as true under the penalties of perjury.
A bid shall not be considered for award nor shall any award be made
where (1) , (2) and (3) above have not been complied with; provided however,
that if in any case the bidder cannot make the foregoing certification,
the bidder shall so state and shall furnish with the bid a signed statement
which sets forth in detail the reasons therefor. Where (1) , (2) and (3)
(b)
above have not been complied with, the bid shall not be considered for award
nor shall any award be made unless the head of the purchasing unit of the
Town, or Town Department, to which the bid is made, or his desionee, deter-
mines that such disclosure was not made for the purpose of restricting com-
petition.
The fact that a bidder has published price lists, rates, or tariffs
covering items being procured, has informed prospective custorers of pro-
posed or pending publication of new or revised price lists for such items ,
or has sold the same items to other customers at the same prices being bid,
does not constitute, without more, a disclosure within the meaning of the
paragraphs (1), (2) and (3) above.
Any bid hereafter made to the Tcwn or Town Department, or official
thereof by a corporate bidder for work or services performed or to be per-
form- ed or goods sold or to be sold, where competitive bidding is required
by statute, rule or regulation, and where such bid contains the certifica-
tion set forth above shall be deemed to have been authorized by the board
of directors of the bidder, and such authorization shall be deemed to in-
clude the signing and submission of the bid and the inclusion therein of
the certificate as to non-collusion as the act and deed of the corporation.
SECTION 3. TAX PROVISION:
Purchases made by the Town of Hempstead are not subject to state or
local sales taxes or federal excise taxes. There is no exemption from pay-
ing the New York State truck mileage, unemployment insurance, or Federal
social security taxes.
The official Town purchase order or voucher for materials, equipment
and supplies is sufficient evidence to qualify the transaction exempt from
sales tax under Section 1116(a) (1) , Tax Law.
t For tax free transactions under the Internal Revenue Code, the Town
registration number-is 11-6001929 W.
SECTION 4,
TFe entire bid is understood to be in accordance with the specifica-
tions and this proposal unless the bidder explains in detail .
(c)
DECLARATIONS INSURANCE AGENTS' AND BROKERS' ERRORS AND OMISSIONS POLICY
LICY
NUMBER 8-05 ME- 607 8 3 63
FIREMAN'S FUND INSURANCE COMPANIES
COVERAGE IS PROVIDED IN THE FOLLOWING
-POLICY 6/19/87 6/19/88 COMPANY, A STOCK COMPANY.
PERIOD: FROM TO
(12:01 A.M. STANDARD TIME AT PLACE OF ISSUANCE) 0 Fireman's Fund Insurance Co.
J
INSURED'S NAME AND MAILING ADDRESS
Roy H. Reeve Agency, Inc.(See 180009 att'd)
Main Road, P.O. Box 54
Mattituck, NY 11952
LIMITS OF LIABILITY AMOUNT DEDUCTIBLE PREMIUM
p
$ 11000,000 EACH CLAIM $ 1,500,000 AGGREGATE $ 5,000 EACH CLAIM $ 7,955
INSTALLMENTS ARE PAYABLE
ON INCEPTION DATE FIRST ANNIVERSARY SECOND ANNIVERSARY
$
$ $
In consideration of the stipulations herein named and of the above specified premium, this Company, for the term beginning and ending on the dates shown
above, does insure the above named Insured as herein provided.
1. Definition of Insured. The unqualified word "Insured" includes the named Insured,any partner,director or executive officer the while acting in his capacity
as such, and any licensed solicitor or office broker named in the following schedule of additional insureds or other employee employed by the named Insured while
acting within the scope of his duties as such. The individual solicitors or brokers,if any,thus designated in the schedule of additional insureds,shall be additional
insureds only as respects insurance handled through or placed with the named Insured.
Schedule of Licensed Solicitors and Office Brokers as Additional Insureds:
Melinda L. Topping Charles H. Smith
Walter Orlowski Barbara J. Allen
Edward Lenceski
2. Insuring Clause. This insurance,subject to the terms and conditions hereof, will pay on behalf of the Insured all sums which the Insured shall become obligated
to pay by reason of liability for breach of duty as Insurance Brokers, Insurance Agents or General Insurance Agents, claim for which is made against them during
the period stated hereinbefore by reason of any negligent act, error or omission, whenever or wherever committed or alleged to have been committed, on the part
of the Insured or any person who has been, is now, or may hereafter during the term of this insurance be employed by the Insured, in the conduct of any business
conducted by or on behalf of the Insured in their capacity as Insurance Brokers, Insurance Agents or General Insurance Agents.
3. Exdusions- This insurance shall not apply in respect of any claim
(a) for libel or slander;
(b) brought about or contributed to by the dishonest, fraudulent, criminal, or malicious act or omission of the Insured or any employee of the Insured.
4. Limits of Liability. The liability of this Company for each claim shall not exceed the amount shown above as applicable to "each claim," and, subject to that
limit for each claim, the total limit of this Company's liability for all claims covered hereunder and occurring during each policy
shown above as "aggregate." The inclusion herein of more than one Insured shall not operate to increase the limit of the Company's I abili exceed the amount
P Y ty. •'
5. Deductible Clause. It is understood and agreed that in event of a claim the amount of the deductible shown above shall be deducted from the amount of each
claim payable hereunder when determined. Such deductible shall not apply, however, to supplementary Payments as provided under clause (6) of this policy.
ENDORSEMENTS ATTACHED
(Continued on Page Two)
135217(9-68) , 135198(3-68) , 180009(6-65) , 135296(2-78)
I
THIS POLICY IS MADE AND ACCEPTED SUBJECT TO THE FOREGOING STIPULATIONS AND CONDITIONS AND TO THE CONDITIONS PRINTED ON THE BACK HEREOF,
WHICH ARE HEREBY SPECIFICALLY REFERRED TO AND MADE A PART OF THIS POLICY, together with such other provisions, agreements or conditions as may be
endorsed hereon or added hereto; and no officer, agent or other representative of this Company shall have power to waive or be deemed to have waived any provi-
sion or condition of this Policy unless such waiver, if any, shall be written upon or attached hereto, nor shall any privilege or permission affecting the insurance
under this Policy exist or be claimed by the Insured unless so written or attached.
IN WITNESS WHEREOF. THE COMPANY HAS CAUSED THIS POLICY 10 BE EXECUTED AND ATTESTED, BUT THIS POLICY SHALL NOT BE VALID
VNLESS COUNTERSIGNED BY A DULY AUTHORIZED REPRESENTATIVE OF THE COMPANY.
J
SECRETARY
COUNTERSIGNEDATPRESIDENT
DATE COUNTERSIGNATURE OF AUTHORIZED AGENT
5712-2-65 (REV. 8-82) VB ban 6Z11/87
Page 1 of 3
I
DEPARTMENT— AGENTS LICENSE UNDER SECTION 2103(b),INSURANCE LAW
STATE OF NEW YORK, INSURANCE 017397 ' •
V. STED M HM,DOES HEREBY AUTHORIZE THE LICENSEE NAMED BELOW
THE SUPERINTENDENT OF INSURANCE OF THE STATE OF NEW YORK,BY VWUE ��((EE
TO ACT AS AGENT IN RESPECT TO THE KIND OR KINDS OF INSURANCE INOICATED BELOW, pURSUART TO ITE P110VLSIONS OF BECKON 2103(b) OF THE INSURANCE LAW.
H 1-
7-INLAND MARE B OCEAN MARINE
FIRE 2-CASUALTY 3-FIDELITY 6 SURETY 6-BAG e-CREDIT - x
X '.X X X
X X tX
CORPORATION
C
T
30 1988
HIS UCENSE E LICENSE NUMBER
PC-650142
n
REEVE ROY H AGENCY I t zr
MAIN RD PO BOX 54 ,
FORM #�ATT LTJ C K NY 1195 2 «�,�" �J Th'Isn 1.b evades ipreas d behalf
I,Itr,dn a trartsaet liminess an limen
which has appointed
fit.
�6 r ��' 0 terminates a
�Nt1 ... �E ��
T a until se licenseOr
by ft
a k sooner '..
F PARTNERSHIP
all CDRPORATgN Br PND THROUGH 111E SUB LICEISEEISI NAMEn oN ATTAOfED CND(S) JA ME P- C 0 R C 0 R A N---.,-
Jn �Uitness1)ercuf, I HAVE CAUSED MY OFFICIAL SEAL TO BE AFFIXED AT THE CITU OF ALBANY SUPERINTENDENT OF INSURANCE
JULY 19 1986
I - 4
STATE OF NEW PORK, INSURANCE DEPARTMENT— AGENT'S LICENSE UNDER SECTION 2103(a),INSURANCE LAW
THE SUPERINTENDENT OF INSURANCE OF THE STATE OF NEW YORK,BYVIRTUE -!`a*RITY JESTED IN Vim,DOES HEREBY AUTHORIZE THE LICENSEE NAMED BELOW TO 15884,6
ACT AS AGENT IN RESPECT TO THE KIND OR KINDS OF INSURANCE INDICATED BELOW,PURSUANT TO THE PROVISIONS OF SECTION 2103(a)OF THE INSURANCE LAW.
LIFE VARIABLE ANtQMIES ACCIDENT&HEALTH TRAVEL ACCIDENT
X X X CORPORATICi
THIS LICENSE EXPIRES JUNE 30, 1989 LICENSE NUMBER
r
REEVE ROY H AGENCY INC '' LA-650142
MAIN RU PO B -
OX 54
FORM
LA-5 MATTITUCK NY 11952 -
_ This license entities the agent named
_ herein to transact business on behalf
of any company or society which
has appointed him under this
license,unlit such time as the com
- Deny of society terminates the ap-
pointment,or until the license ex.
pires-a is sooner suspended or
IF PARTNERSHIP OR CORPORATION,BY AND THROUGH THE SUR-UCENSEEIS)NAMED ON ATTACHED CARD(S) revoked by the Superintendent
In Witness 31114erii I HAVE CAUSED MY OFFICIAL SEAL TO BE AFFIXED AT THE CITY OF ALBANY JAMES P• C C R C C R A N
JULY 12 1910-7 SUPERINTENDENT OF INSURANCE
SEP 23
Y1ft*EMk INSURANCE AGENT/BROKER QUALIFICATIONS
The Town of Southold is placing their automobile coverages,
comprehensive general liability, and property for proposals,
utilizing direct writers, agents/brokers. We have retained
the service of William F. Mullen, Jr. , as our Risk Manager,
who may be contacted regarding any questions pertaining to
requalifications and insurance specifications by writing to
the Town of Southold, 53095 Main Road, P.O. Box 1179, Southold,
New York, 11971.
We naturally, will require certain basic qualifications
and, thus, the completion of the attached questionaire is of
the utmost importance.
Market Asignment for the major exposures will be made
by the Supervisor and Town Councilpeople of the Town with
the assistance of their Risk Manger, and only those markets
which will be assigned will be acceptable by the Village.
The prequalification questionaire is attached and
must be returned no later than September 24 , 1987 and
the market assignment will be made by the Town on or about
October 1, 1987
It is, therefore, requested that you complete the enclosure
which will require markets perferred together with your current
annual premium volume:
It will be necessary that you provide and take into
consideration the following qualifications:
1. Photosat of current Broker' s license and if qualified,
Excess Lines Broker' s license, issued by the Insurance Department
of the State of New York.
1
2. A minimum of five (5) years in business.
3. Annual premium volume of at least $1, 000 , 000. excluding
life, accident, and health.
4. Two_iggalified principals who have at least five
(5) years experience in commercial accounts. The successful
bidder will be required to meet with designated personnel
of the Town of Southold by not later than Dec. 10,1987 to coordinate
the service of their insurance program.
5. The successful bidder shall provide evidence such
as Certificate of Insurance of Agent/Brokers and errors and
ommissions insurance with minimum limits of $1, 000 , 000. per
occurance.
• 6. Compliance with therequirements of the Equal Employment
Opportunity Agency where applicable. (Speciman copy attached
hereto) .
7. Agreement to prepare semi-annual reports to the
Town of Southold regarding premiums and losses byclassification
and advise, also, any unique or exceptional coverage changes
at the same time.
If there are any questions regarding the completion
of this questionaire, please address it to the Town of Southold,
53095 Main Road, P.O. Box 1179, Southold, New York, 11971.
1
i. 1 • •
REaWE►D
VEP 23 TOWN OF SOUTHOLD
1�w�t�lwit PRE-4UALik-iCATION 4UES�rlUNNH1xE
iw/NY
Date: 9/22/87
Name OIL Firm Val Stype & Sons, Inc
Servicing Offioe Address Main Rd PO Box 63
Mattituck, NY 11951
Z ip 11952 Phone 516 298-8481
I. Total num _r of professional staff 6
Total number of clerical/support staff 3
2. Please attach evidence of current insurance agents '/brokers '
errors and ommissions insurance with a minimum limit of
$1, 000, 000.. per occurrence.
3 . Please attach statement certifying compliance with the
.:req-uirements of the Equal Employment Opportunity Acta
....(Copy attached)
4 . Is marketing to excess and surplus lines -
(a) Direct or
(b) Other areas_- through a Managing General Agent
S. Please list any special services available (safety, loss
prevention, claims adjustment, EDP claims, reports, etc. ) :
From within Firm From Insurance Companies or Others
safety, loss prevention, claims adjustment
6 . How often will you review claims and reserves with Village?
on what the Town would like us to do.
7 . List in order of preference those markets which your
firm would wish to approach for insurance, showing
servicing office ' s current total annual premium volume
7. for each market.
Liability (Auto and General)
1) (STA $650,000
2) Continental Insurance Company $350,000
Property
1) CNA
2) Continetal
8. Provide any other information about your firm which
might be pertinent to selection.
-On the rttrrnrit Q= ani ps 77Gx3 for the ihnhral l a' PitbL off;nal c and
nthar r-nvaragpg� Tera czi l 1 tri, to gat ranacm'1 =7otac frnm therm
Name of Person Completing Questionnaire
John V Stene
Signat
Title:
�P("YPta r;7 - �rY'Pa�`i IYPY
•
STATE OF NEW YORK, INSURANCE DEPARTMENT-BROKER'S UCENSE UNDER SECTION 2104,INSURANCE LAW 37089
THE SUPERINTENDENT OF INSURANCE OF THE STATE OF NEW YORK,BY VIRTUE OF THE AUTHORITY VESTED IN HIM BY
SECTION 2104 OF THE INSURANCE LAW.DOES HEREBY AUTHORIZE THE LICENSEE NAMED BELOW TO ACT AS BROKER IN OBTAINING AND
PLACING INSURANCE UPON PROPERTY AND RISKS IN THE STATE OF NEW YORK.AS PROVIDED IN SAID SECTION UNTIL THE EXPIRATION
DATE SHOWN HEREON,UNLESS THIS LICENSE IS SOONER SUSPENDED OR REVOKED, CORPORATION
THIS LICENSE EXPIRES O C TO 3 E R 31. 1 2 3 8 LICENSE NUMBER
r
FORM 795 STYPE VAL AND SONS INC 138123
MAIN RD
MATTI TJCK NY 11952
IF PARTNERSHIP OR CORPORATION,BY AND THROUGH THE SUB-LICENSEE(S)NAMED ON ATTACHED CARDS '
NOVEM'?ER 31, 1935
In Illitnees IU#trtnf. 141AVE CAUSED MY OFFICIAL SEAL TO BE AFFIXED AT THE CITY OF ALBANY JAMESCORCORAN
SUPERINTENDENT OF INSURANCE
I
I
STATE OF N EW YORK. INSURANCE DEPARTMENT-PARTNERSHIP OR CORPORATION SUB-LICENSEES AUTHORIZED TO ACT UNDER 29870
EXPIRES 0 C T 03 E R 31 I 19 38 TITLE LICENSE NUMBER
STYPE ANDREW D 138123
STYPE VALENTINE W JR
STYPE JOHN V
SUB
LICENSEES
FORM 798 - -
I i
I ,
r
1
r
C�CO�C�® ISSUEDATE(MM/DD/YY) --
09/23/87
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
Val Stype & Sons, Inc NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOESNOT AMEND,
PO Box 63 EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Mattituck,NY 11952 COMPANIES AFFORDING COVERAGE
LETTERNY A Fireman Fund Ins CO
COMPANY
INSURED LETTER B
Val Stype & Sons, Inc. COMPANY
PO BOX 63 LETTER c
Mattltuck, NY 11952 COMPANY
LETTER
COMPANY E
LETTER
di1�hI:LT�
THIS IS TO CERTIFY THAT 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 CONDI-
TIONS OF SUCH POLICIES.
CO POLICY EFFECTIVE POLICY EXPIRATION LIABILITY LIMITS IN THOUSANDS
TYPE OF INSURANCE POLICY NUMBER ---
LTR DATE(MM/DD/YY) DATE(MM/DD/1'Y) "" EACH AGGREGATE
_- -- -- OCCURRENCE
GENERAL LIABILITY
BODILY
COMPREHENSIVE FORM INJURY $ $
PREMISESIOPERATIONS PROPERTY
UNDEEXPLOSION COLLAPSE HAZARD ND DAMAGE $ $
PRODUCTS/COMPLETED OPERATIONS
CONTRACTUAL BI&PD
COMBINED $ $
INDEPENDENT CONTRACTORS
BROAD FORM PROPERTY DAMAGE
PERSONAL INJURY PERSONAL INJURY $
A X Errors and Omissio ME 637-15-75 8/1/87 8/1/88 1,000
AUTOMOBILE LIABILITY BODILY
NJURY
ANY AUTO (PER PERSON) $
ALL OWNED AUTOS(PRIV. PASS.) BODILY
OTHER THAN NJURY
ALL OWNED AUTOS PRIV. PASS.I (PER ACCIDENT) $
HIRED AUTOS
PROPERTY
NON-OWNED AUTOS DAMAGE $
GARAGE LIABILITY
[BI a PDOMBINED $
EXCESS LIABILITY
UMBRELLA FORM BI&PD
COMBINED $ $
OTHER THAN UMBRELLA FORM
WORKERS'COMPENSATION STATUTORY
AND $ (EACH ACCIDENT) �
EMPLOYERS' LIABILITY 1$ (DISEASE-POLICY LIMIT)
$ (DISEASE-EACH EMPLOYEE)
JOTHER -
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/SPECIAL ITEMS
Tbm of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX-
PIRATION DA E THEREOF, T ISSUING COMPANY WILL ENDEAVOR TO
Main Rd MAIL Y WRITTEN NO TO THE CERTIFICATE HOLDER NAMED TO THE
Southold, NY 11971 LEFT,BUT FAI TO SUCIINPTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND T E P ITS AgEhTS OR REPRESENTATIVES.
---
(AUTHORIZED REP NI
e[K�•• .oZL-7�Z�Ii]:i�iL•T�[i1►1f[s71f
SEP 21 TOWN OF SOUTHOLD
PRE-4UAL.Lr'1CATION 4UESTiuNNAiitE
i To" C
Date: Sp=rpm_�f3� 1987
Name of Firm- Griffing & Southwick, Inc.
Servicing Offi=e Address 55 North Ferry Road
Shelter Island, N.Y. •11964
Zip 1 1964 Phone 516-749-0484
1. Total numl er of professional staff three
Total number of clerical/support staff three
2. Please attach evidence of current insurance agents '/brokers '
errors and ommissions insurance with a minimum limit of
.$1, 000, 000.. per occurrence.
3 . Please attach statement certifying compliance with the
requirements of the Equal Employment Opportunity Acta
..(Copy attached)
4 . Is marketing to excess and surplus lines -
li (a) Direct pr through varioW Surplus
Lines Brokers
(b) Other areas
S . Please list any special services available (safety, loss
prevention, claims adjustment, EDP claims, reports, etc. ) :
From within Firm From Insurance Companies or Others
CIGNA Insurance Companies Loss Control Department,
Cigna EDP Claims reports
6 . How often will you review claims and reserves with Village?
Ever two months or review of unusual claims, or claims
re ebt on by loss history
r t •
7 . List in order of preference those markets which your
firm would wish to approach for insurance, showing
servicing office 's current total annual premium volume
for each market.
Liability (Auto and General)
1) CIGNA Insurance Companies $2,346, 136
2)
Property
1) Cigna Insurance Companies $2,346, 136
2)
8 . Provide any other information about your firm which
might be pertinent to selection.
Previous Broker for Town Of Riverhead, until the new self
insurance pmgram started in Feb 1987
Present Broker fok the Town of Shelter Island
Name of Person Completing Questionnaire
William C. Sout wick, Pres.
Signature:
Title: President
t
Griffing&Southwick,Inc.
55 North Ferry Road
Shelter Island,NY 11964
(516)749-0484
This is to certify that Griffing & Southwick, Inc . of
55 North Ferry Road , Shelter Island , NY 11964 complies
with the requirements of the Equal Employment Opportunity
Act .
President
Agents for Insurance Company of North An-er+ca Aofro osurance Company and Bankers Standard Insurance Company. CIGNA companies
i
y S
DECLARATIONS INSURANCE AGENTS' AND BROKERS' ERRORS AND OMISSIONS POLICY
POLICY
NUMBER 8-05 ME- 607 91 70 CORRMAN'AGE ISPROrVUB VIDEDNpTHHEu OLLLOW NG �MPAIiIIES
ING
POLICY 01/01/87;, – t:;� 01/01/88 COMPANY A.STOCK COMPANY;
PERIOD: FROM TO .><; Me+ y
:t. .
(12:01 A.M. STANDARb TIME AT PLACE OF ISSUANCE) O1 1,"Fi'remdn's Fund `Insurance''Co.
I
INSURED'S NAME AND MAILING ADDRESS " , :•.: h
Griffing`& Sbuthwick , Inc. "' $
55 North Ferry Rd. u
Shelter Island, NY 11964
I
AMOUN�^OERLJCf1E11.6�1 ) r s � PREMIUM
au l �lM1TG{?i'siE IfaBILITY Ery ,.t r
� p
$ 1_10001000EACH CLAIM s., 3 000,000 AGGREGATE s 2,500 EACH CLAIM $ 2,772•
ON INCEPTION DATE FIRST ANNIVERSARY SE20Nf6 ANNIVERSARY
INSTALLMENTS ARE PAYABLE
In consideration of the stipulations herein named and of the above specified premium, this,Compsny, for the term beginning and ending on the dates shown
above, does insure the above named Insured as herein provided.
1. Definition of Insured. The unqualified word "Insured" includes the named Insured,any partner,director or executive officer thereof while acting in his capacity
i as such,and any licensed solicitor or office..broker named in the following schedule of additional insureds or other employee employed by the namedAnsured while
acting within the scope of his duties as such. The individual solicitors or brokers,if any,thus designated in the schedule of;additional insureds,,shall be additional
Insureds only as respects Insurance handled through or placed with the named Insured.
Schedule of Licensed Solicitors and Office.Brokers as Additional Insureds:
2. Insuring Clause.This insurances subject to the terms and conditions hereof,will pay on behalf of the Insured all eume which,the Insured shall become obligated
to pay by reason of liability for breach of duty as Insurance Brokers, Insurance Agents or General Insurance Agents,claim for which Js made,against them during
the period stated hereinbefore by reason.of any negligent act, error or omission,whenever or wherever committed or alleged to hove.been committed,ofl'the part
of the Insured or any person who has been,is now,or may hereafter during the term of this insurance be`employed by the Insured in•the conduct of any business
conducted by or'on behalf of the Insured in their cipacity as Insurance Brokers, Insurance Agents or General Insurance Agents.
3. Exdushms. This insurance shall not apply in respect of any claim
(a) for libel or slander, a:_, •, , . . r , r,�s} . ;
(b) brought about or contributed to by the dishonest, fraudulent, criminal, or malicious act or bmission of the Insured or any employee of'tha Insured.
4. Limits of.Liability. The liability of this Company,for each claim shall not exceed the amount shown above as applicable to "each claim," and, subject to that
limit for each claim,the total'iimit of this Company's liability for all claims covered hereunder and oi�curring during each pblicy'year shall'notexceed the amount
shown above as"aggregate'." The inclusion herein of more than one Insured shall not operate to increase`the limit of the Company's'liability. °
S. Deductible Clause.,lt is understood and,agreedthat in event of a claim the amount of the deductible,shown above�shaiPbe deductsitlrom the amount of each
claim payable hereunder when determined.,Such deductible shall not apply, however,to supplementary payments as provided under clause (6) of this policy.
ENDORSEMENTS ATTACHED .(Continued on Page Two)
'135217(9/68) 135296(2/78) 135198(3/68-)- 109009(61651'
THIS POLICY IS MADE AND ACCEPTED SUBIECT;TO THE FOREGOING STIPULATIONS AND CONDITIONS`AND TO THE CONDITIONS PRINTED'ON'7HE BACK HEREOF,
WHICH ARE HEREBY SPECIFICALLY-REFERRED;TO AND MADE A PART.OF THIS POLICY, togetlir`"irith 6flch"other provisions;agreetheirlvor tonditions as°may, be '
endorsed hereon or added hereto; and no officer,agent or other representative of this Company shall have power to waive or be deemed to have waived any provi-
sion or condition of this Policy unless such,waiver, if any,shall be written upon or attached hereto nor shall any pnvilege,or perTisslon affsong the insurance
under this Policy,exist or be claimed by the Insured unless so written or attached.
IN WITNESS WHEREOF,THE COMPANY HAS CAUSED T+118 POLICY 10 BE EXECUTED AND ATTESTED, BUT THIS POLICY`SHALL NOT BE VALID
UNLESS COUNTERSIGNED BY A DULY AUTHORIZED REPRESENTATIVE OF THE COMPANY.
gli
All
Y Je
SECRETARY- , PRESIDENT
COUNTERSIGNEDAT DATE COU TERSIGNATURE OF AUTHORIZED AGENT
Vb/cmp 12/19/86 ,f
5712-2-65(REV. 8-82) r. ' Page 1 of 3
1 STATE OF NEW YORK,�NSIJRANCE DEPARTMENT-BOUTS Uc�SE UNO S 2'04'R�SURA'�CE 36946
1
THE SUPEIHNTEMDENT OF INSURANCE OF THE STATE OF NEW YORK,BY VIRTUE OF THE AUTHORITY VESTED IN HIM BY
SECTION 2104 OF THE INSURAM LAW,DOES INi11EBY AUTHI"Un THE LICENSEE NAMED BELOW TO ACT AS BROKER IN OBTAINING AND
PLACING INSURANCE UPON PROPERTY AND RIBM IN THE STATE OF NEW YORK.AS FROYIDED O SAID SECTION UNTIL THE EXPIRATION CORPORATION
DATE SHOWN HEREON,UNLESS THIS LICENSE IS SOONER SUSPENDED OR REVOKED.
CSF NC yl,�..�
THIS LICENS `EMPIRES°� LICENSE NUMBER
En Lr.1
141124
FORM AUS GR I F F I N G &
55 N FERRY R
SHELTER ISLA
.-
IF PARTNERSHIP OR CORPORATION,BY AND THROUGH THE SUB-LICENSEE(S)NAMED ON ATTACHED CARDS
y�
NOVEMBER 01 1986 J A M E S SUPENRNAIRS 9 9844'Jn�ltpCH16 �tCtNTf• I HAVE CAUSED Mr OFFICIAL SEAL TO BE AFFIXED AT THE CITYY OF ALBANY
r
STATE OFNEW�EW YORK INSURANCE DEPARTMENT-PARTNERSHIP OR COIWOMTION SUB-L SEES AUTHOR To ACT uNm 29727 '
17 -i r�O
EXPIRES OCTOBER 31 1 1 988 TITLE L,ICENBE_NUMBER
SOUTHWICK WILLIAM C 141124
SOUTHWICK. MARGARll
SUB
LICENSEES -�-
t
FORM AUS "
ti
I
INSURANCE - BROKER QUALIFICATIONS
2.
s
3. l9f .
4. A to, /.�Q.C,n, '6w.. C
5. J
6.
INSURANCE AGENT/BROKER QUALIFICATIONS
The Town of Southold is placing their automobile coverages,
comprehensive general liability, and property for proposals,
utilizing direct writers, agents/brokers. We have retained
the service of William F. Mullen, Jr. , as our Risk Manager,
who may be contacted regarding any questions pertaining to
requalifications and insurance specifications by writing to
the Town of Southold, 53095 Main Road, P.O. Box 1179, Southold,
New York, 11971.
We naturally, will require certain basic qualifications
and, thus, the completionof the attached questionaire is of
the utmost importance.
Market Asignment for the major exposures will be made
by the Supervisor and Town Councilpeople of the Town with
the assistance of their Risk Manger, and only those markets
which will be assigned will be acceptable by the Village.
The prequalification questionaire is attached and
must be returned no later than September 24, 1987 and
the market assignment will be made by the Town on or about
October 1, 1987
It is, therefore, requested that you complete the enclosure
which will require markets perferred together with your current
annual premium volume.
It will be necessary that you provide and take into
consideration the following qualifications:
1. Photosat of current Broker' s license and if qualified,
Excess Lines Broker'.s license, issued by the Insurance Department
of the State of New-, York.
2. A minimum of five (5) years in business.
3. Annual premium volume of at least $1, 000, 000. excluding
life, accident, and health.
4. Two_:qualified principals who have at least five
(5) years experience in commercial accounts. The successful
bidder will be required to meet with designated personnel
of the Town of Southold by not later than Dec. 10,1987 to coordinate
the service of their insurance program.
5. The successful bidder shall provide evidence such
as Certificate of Insurance of Agent/Brokers and errors and
ommissions insurance with minimum limits of $1, 000, 000. per
occurance.
6. Compliance with the- requirements of the Equal Employment
Opportunity Agency where applicable. (Speciman copy attached
hereto) .
7. Agreement to prepare semiannual reports to the
Town of Southold regarding premiums and losses by-,classification
and advise, also, any unique or exceptional coverage changes
at the same time.
If there are any questions regarding the completion
of this questionaire, please address it to the Town of Southold,
53095 Main Road, P.O. Box 1179, Southold, New York, 11971.
TOWN OF SOUTHOLD
PRE-QUALir KATION QUESTiuNNaixE
Date:
Name of Firm:
Servicing Off ice Address
ZiP Phone
1. Total number of professional staff
Total number of clerical/support staff
2. Please attach evidence of current insurance agents'/brokers '
errors and ommissions insurance with a minimum limit of
$1, 000, 000.. per occurrence.
3 . Please attach statement certifying compliance with the
.requirements of the Equal Emplo
(Copy attached) yment Opportunity Acta
4 . Is marketing to excess and surplus lines -
(a) Direct or
(b) Other areas
5 . Please list any special services available (safety, loss
prevention, claims adjustment, EDP claims, reports, etc. ) :
From within Firm From Insurance Companies or Others
6 . How often will you review claims and reserves with Village?
7 . List in order of preference those markets which your
firm would wish to approach for insurance, showing
servicing office 's current total annual premium volume
for each market.
Liability (Auto and General)
1)
2)
Property
1)
2)
8. Provide any other information about your firm which
might be pertinent to selection.
Name of Person Completing Questionnaire
Signature:
Title:
BIDDER: SECTIONS I THROUGH 4 ARE PART OF THIS PROPOSAL
• SECTION 1. ANTI-DI SCRIM11NATION CLAUSE:
During the performance of this contract, or bid, the contractor
agrees as fol?ows:
(a) The contractor will not discriminate against any eimployee or
applicant for employment because of race, creed, color, sex, or national
origin, and will take affirmative action to insure that they are afforded
equal employment opportunities without discrimination because of race,
creed, color, sex, or national origin. Such action shall be taken with
reference, but not be limited, to: recruitment, employment, job assign-
ment, promotion, upgrading, demotion, transfer, layoff or termination,
rates of pay or other forms of compensation, and selection for training
or retraining, including apprenticeship and on-the-job training.
(b) The contractor will send to each labor union or representative
of workers with which he has or is bound by a collective bargaining or
other agreement or understanding, a notice, to be provided by the State
Comiission for Human Rights, advising such labor union or representative
of the contractor's agreement under clauses (a) through (g) (hereinafter
called "non-discrimination clauses") . If the contractor was directed to
do so by the Town as part of the bid or negotiation of this contract, the
contractor shall request such labor union or representative to furnish
him with a written statement that such labor union or representative will
not discriminate because of race, creed, color, sex, or national origin
and that such labor union or representative either will affirmatively co-
operate, within the limits of its legal and contractual authority, in the
implementation of the policy and provisions of these non-discrimination
clauses or that it consents and agrees that recruitment, employment and
the terms and conditions of employment under this contract shall be in
accordance with the purposes and provisions of these non-discrimination
clauses. If such labor union or representative fails or refuses to com-
ply with such a request that it furnish such a statement, the contractor
shall promptly notify the State Commission for Human Rights of such fail-
ure or refusal .
(c) The contractor will post and keep posted in conspicuous places,
available to employees and applicants for employment, notices to be pro-
vided by the State Commission for Human Rights setting forth the substance
of the provisions of clauses (a) and (b) and such provisions of the State's
laws against discrimination as the State Commission for Human Rights shall
determine.
(d) The contractor will state, in all solicitations or advertisements
for employees placed by or on behalf of the contractor, that all qualified
applicants will be afforded equal employment opportunities without dis-
crimination because of race, creed, color, sex, or national origin.
(e) The contractor will comply with the provisions of Sections 291-
299 of the Executive Law and the Civil Rights Law, will furnish all inform-
ation and reports deemed necessary by the State Commission for Human Rights
under these non-discrimination clauses and such sections of the Executive
.Law, and will permit access to his books, records and accounts by the State
Commission for Human Rights, the Attorney General and the Industrial Commis-
sioner for purposes of investigation to ascertain compliance with these non-
discrimination clauses and such sections of the Executive Law and Civil
Rights Law.
(a)
(f) This contract .:ay be forthwith canceled, terminated or suspended,
in whole or in part, by the Town upon the basis of a finding made by the
State Co-mission for Human Rights that the contractor has not complied with
these non-discrimination clauses , and the contractor may be declared in-
eligible for future contracts rade by or on behalf of the Town, until he
satisfies the State Cornission for Hunan Rights that he has established and
is carrying out a program in conformity with the provisions of these non-
discrimination clauses. Such finding shall be made by the State Commission
for Human Rights after conciliation efforts by the Commission have failed
to achieve compliance with these non-discrimination clauses and after a
verified complaint has been filed with the Com fission, notice thereof has
been given to the contractor and an opportunity has been afforded him to
be heard publicly before three members of the Co..mission. Such sanctions
may be imposed and remedies invoked independently of or in addition to
sanctions and remedies otherwise provided by law.
(g) The contractor will include the provisions of clauses (a) through
(f) in every subcontract or purchase order in such a manner that such pro-
visions will be binding upon each subcontractor or vendor as to operations
to be performed within the State of New York. The contractor will take
such action in enforcing such provisions of such subcontract or purchase
order as the Town may direct, including sanctions or remedies for non-
compliance. If the contractor becomes involved in or is threatened with
litigation with a subcontractor or vendor as a result of such direction
by the contracting agency, the contractor shall promptly so notify the
Attorney .General , requesting him to intervene and protect the interests
of the Town.
SECTION 2. -NON-COLLUSIVE BIDDING CERTIFICATION:
By submission fo this bid, each der aTnT each person signing on
behalf of any bidder certifies, and in the case of a joint bid each party
thereto certifies as to its own organization, under penalty of perjury,
that to the best of his knowledge and belief:
(1) The prices of this bid have been arrived at independently with-
out collusion, consultation, communication, or agreement, for the purpose
of restricting competition, as to any matter relating to such prices with
any other bidder- or with any competitor;
(2) Unless otherwise required by law, the prices which have been
quoted in this bid have not been knowingly disclosed by the bidder and
will not knowingly be disclosed by the bidder prior to opening, directly
or indirectly, to any other bidder or to any competitor;
and (3) No attempt has been made or will be made by the bidder to in-
duce any other person, partnership or corporation to submit or not to sub-
mit a bid for the purpose of restricting competition.
NOTE: Chapter 675 of the Laws of New York for 1966 provides that
every bid made to the Town or any Town department, agency or official there-
of, where competitive bidding is required by statute, rule or regulation,
for work or services performed or to be performed or goods sold or to be
sold, shall contain the foregoing statement subscribed by the bidder and
affirmed by such bidder as true under the penalties of perjury.
A bid shall not be considered for award nor shall any award be made
where (1) , (2) and (3) above have not been complied with; provided however,
that if in any case the bidder cannot make the foregoing certification,
the bidder shall so state and shall furnish with the bid a signed statement
which sets forth in detail the reasons therefor. Where (1) , (2) and (3)
(b)
above have not been complied with, the bid shall not be considered for award
nor shall any award be made unless the head of the purchasing unit of the
Town, or Town Department, to which the bid is made, or his desionee, deter-
mines that such disclosure was not rnade for the purpose of restricting com-
petition.
The fact that a bidder has published price lists, rates, or tariffs
covering items being procured, has informed prospective customers of pro-
posed or pending publication of new or revised price lists for such items ,
or has sold the same iters to other customers at the same prices being bid,
does not constitute, without more, a disclosure within the meaning of the
paragrap'-;s (1) , (2) and (3) above.
Any bid hereafter made to the Tewn or Town Department, or official
thereof by a corporate bidder for work or services performed or to be per-
form- ed or goods sold or to be sold, where competitive bidding is required
by statute, rule or regulation, and where such bid contains the certifica-
tion set forth above shall be deemed to have been authorized by the board
of directors of the bidder, and such authorization shall be deemed to in-
clude the signing and submission of the bid and the inclusion therein of
the certificate as to non-collusion as the act and deed of the corporation.
SECTION 3. TAX PROVISION:
Purchases made by the Town of Hempstead are not subject to state or
local sales taxes or federal excise taxes. There is no exemption from pay-
ing the New York State truck mileage, unemployment insurance, or Federal
social security taxes.
The official Town purchase order or voucher for materials, equipment
and supplies is sufficient evidence to qualify the transaction exempt from
sales tax under Section 1116(a) (1) , Tax law.
For tax free transactions under the Internal Revenue Code, the Town
_, registration number-is 11-6001929 W.
SECTION 4,
--fFe-entire bid is understood to be in accordance with the specifica-
tions and this proposal unless the bidder explains in detail .
(c)
STATE OF NEW YORK )
TOWN OF SOUTHOLD I SS:
GENERALINSURANCE
PROGRAM COUNTY OF SUFFOLK ?
Pre-Qualification
Applications
Pre-Qualification Applica- Christina Contento of Greenport, in
tions for the General Insurance
Program of the Town of South- said County, being duly sworn, says that he/she is
old, for most insurance policies Principal Clerk of THE SUFFOLK TIMES, a Weekly
expiring January 1, 1988, are
available at the Office of the Newspaper, published at Greenport, in the Town
Town Clerk, Town of Southold, of Southold, County of Suffolk and State of New
Town Hall, Main Road, South-
old, New York, and must be re- York, and that the Notice of which the annexed is
turned on or before 5:00 P.M., a printed copy, has been regularly published in
Thursday, Septemer 24, 1987,
after which market assignments said Newspaper once each week for —1
will be made on or before Oc- 17
tober 1, 1987. The bid informa- weeks successively, commencing on the
tion must then be returned to day of September
the Town Clerk not later than
November 30, 1987, and a deci-
sion will be made on or about
December 3,1987.
JUDITH T.TERRY —
_
SOUTHOLD TOWN CLERK Principal Clerk
1TS17-5711
Sworn to b f e 4metisday of — 19 � MARY K.DEGNAN
NOTARY PIBLIC,State of New York
�` Suffolk County No.4849860
Term Expires Februa%"31P�
TOWN of SOUTHOLD COUNTY OF SUFFOLK
GENEEkAL INSURANCE STATE OF NEW YORK ss.
PROGRAM -
Pre-Qualifitgtion Applications
Pre-Qualification Applica Patricia Wood, being duly sworn, says that she is the
tions fnr,the General Insurance
Program of the Town of Editor, of THE LONG ISLAND TRAVELER-WATCHMAN,
Southold, for most insurance a public newspaper printed at Southold, in Suffolk County;
policies.expiring January 1, and that the notice of which the annexed is a printed copy,
1988,are available at the Office
of the Town Clerk, Town of has been published in said Long Island Traveler-Watchman
,Southold, Town Hall, Main once each week for . . . . . . . . . . . . . . . . . . . . . . . . . . . weeks
Road, Southold, New York,
and must be returned on or 7 `#
before 5:00 P.M., Thursday, successively, commencing on the . . . . . . . . . . . . . . . . . . . . . .
September 24, 1987,after which
market assignments will be __
made on or Before October 1, Y • • . • .
1987.The bid information must
then be returned to the Town
Clerk not later than November . . . . • . • • . • • • • • • . • . . • • . • . . . . . . • • . • . • • . • • • • . • • _
30, 1987,and a decisig4n will be
made on or about December 3,
1987.
JUDITH,T. TERRY _77
SOUTHOLD TOWN CLERK Sworn to before me this . . . . . . . . . . . ... . . . . . . . . day of
1T-9/17/87(6)
n ,tt 19 ., 7
. . . . . . . . . . . . .
= -- . . . . . . . . . .
Notary Public
BARBARA FO,RBLS
Notary Pu :.'i State of New York
No. 42(:.g 16
Qaal;ficd in Suffolk County
Coir,:nissi("a Expires 3 /19 ��
COUNTY OF SUFFOLK
ss:
STATE OF NEW YORK
i
i,
Patricia Wood, being duly sworn, says that she is the
j Editor, of THE LONG ISLAND TRAVELER-WATCHMAN,
i
a public newspaper printed at Southold, in Suffolk County;
and that the notice of which the annexed is a printed copy,
has been published in said Long Island Traveler-Watchman
once each week for . . . . . . . . . . . . . . . . . . . . . . . . . . . weeks
successively, commencing on the . . . . . . . . . . .1.7. . . . . . . .
19
Sworn to before me this . . . . . . . . . .. . . . . . . . . . . day of
i
. . . . . . . . . . . . . . . . . .... . . . . . . . . . . ..7��'"' . . . . . . . . . .
Notary Public
BARBARA FORBES
Notary Public, State of New York
No. 4806846
Qualified in Suffolk County
Commission Expires 3 /19
i
I�
�ry'..'�11�nMAnPFS4R�R�enarmimnr n�Ri inma�re�rirnmwPn^ePe�mm�mm�n�PmalPmn^mmni^n m.na,. m,��.^.�.e .,>. ,.,.,, +�s,�is*".�...,�•r
STATE OF NEW YORK)
SS :
COUNTY OF SUFFOLK)
JUDITH T. TERRY, Town Clerk of the Town of Southold, New York,
being duly sworn, says that on the 14th day of September 19 87
she affixed a notice of which the annexed printed notice is a true copy, in
a proper and substantial manner, in a most public place in the Town of
Southold, Suffolk County, New York, to wit:
Town Clerk's Bulletin Board, Southold Town Hall, Main Road,
Southold, New York 11971 .
Requests for Proposals :
Pre-Qualification applications for the General Insurance Program of the Town
of Southold for most insurance policies expiring January 1, 1988.
Judith T. Terry
Southold Town Clerk
Sworn to before me this
14th day of September 19 87
Notary Public
ELIZABETH ANN NEVILLE
Notary Public,State of New York
No.52-8125850,Suffolk Cou
Term Expires October 31,19
TOWN OF SOUTHOLD
�I GENERAL INSURANCE PROGRAM
Pre-Qualification Applications
Pre-Qualification Applications for the General Insurance Program of the
Town of Southold, for most insurance policies expiring January 1, 1988, are
available at the Office of the Town Clerk, Town of Southold, Town Hall, Main
I
Road, Southold, New York, and must be returned on or before 5:00 P.M. ,
Thursday, September 24, 1987, after which market assignments will be made
i I
on or before October 1, 1987. The bid information must then be returned to
the Town Clerk not later than November 30, 1987, and a decision will be made
on or about December 3, 1987.
f
JUDITH T. TERRY
SOUTHOLD TOWN CLERK
r
i
!
PLEASE PUBLISH ONCE, SEPTEMBER 17, 1987, AND FORWARD ONE (1)
AFFIDAVIT OF PUBLICATION TO JUDITH T. TERRY, TOWN CLERK,
TOWN HALL, MAIN ROAD, SOUTHOLD, NEW YORK 11971.
Copies to the following:
The Suffolk Times
The Long Island Traveler-Watchman
Town Board Members
William F. Mullen, Jr. , Consultant
Town Clerk's Bulletin Board
I
I
I.
I�
I
TOWN OF SOUTHOLD
GENERAL INSURANCE PROGRAM
Pre-Qualification Applications
Pre-Qualification Applications for the General Insurance Program of the
Town of Southold, for most insurance policies expiring January 1, 1988, are
available at the Office of the Town Clerk, Town of Southold, Town Hall, Main
Road, Southold, New York, and must be returned on or before 5:00 P.M.,
Thursday, September 24, 1987, after which market assignments will be made
on or before October 1, 1987. The bid information must then be returned to
the Town Clerk not later than. November 30, 1987, and a decision will be made
on or about December 3, 1987.
JUDITH T. TERRY
SOUTHOLD TOWN CLERK
PLEASE PUBLISH ONCE, SEPTEMBER 17, 1987, AND FORWARD ONE (1)
AFFIDAVIT OF PUBLICATION TO JUDITH T. TERRY, TOWN CLERK,
TOWN HALL, MAIN ROAD, SOUTHOLD, NEW YORK 11971.
Copies to the following:
The Suffolk Times
The Long Island Traveler-Watchman
Town Board Members
William F. Mullen, Jr. , Consultant
Town Clerk's Bulletin" Board
N SOUTD
GENERALINSURAN HOLOGRAM
Pre-Qualification Applications
Pre-Qualification Applications for the General Insurance Program of the
Town of Southold, for most insurance policies expiring January 1, 1988, are
available at the Office of the Town Clerk, Town of Southold, Town Hall, Main
Road, Southold, New York, and must be returned on or before 5:00 P.M.,
Thursday, September 24, 1987, after which market assignments will be made
on or before October 1, 1987. The bid information must then be returned to
the Town Clerk not later than November 30, 1987, and a decision will be made
on or about December 3, 1987.
JUDITH T. TERRY
SOUTHOLD TOWN CLERK
PLEASE PUBLISH ONCE, SEPTEMBER 17, 1987, AND FORWARD ONE (1)
AFFIDAVIT OF PUBLICATION TO JUDITH T. TERRY, TOWN CLERK,
TOWN HALL, MAIN ROAD, SOUTHOLD, NEW YORK 11971.
Copies to the following:
The Suffolk Times
The Long Island Traveler-Watchman
Town Board Members
William F. Mullen, Jr. , Consultant
Town Clerk's Bulletin" Board