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HomeMy WebLinkAbout2015 ARD® CERTIFICATE ��aa/►�p ® + DATE(MM/DD/YYYY) 'Li�I�����6d�A C OF LIABILITY E '�07� ��� 7/1/2015 THIS CERTIFICATE IS ISSUED AS A MATE OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ' IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(Les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT L9 Ada GOr(i 1 Ck RECEIVE® NAME: PHONE (516)822-6550 FAX No):(516)622-6564 Prince Associates Inc. I 270 Duffy Avenue E-MAIL Suite D J U L 8 2011 5 INSURERS)AFFORDING COVERAGE NAIC ft . Hicksville NY 11801 INSURER A BanOver Insurance Company INSURED INSURER B: North Fork Animal Welfare Leaguersc6J Did Town Clerk INSURER C: PO Box 297 INSURER D: INSURER E: Southhold NY 11971 INSURER F: COVERAGES CERTIFICATE NUMBERNASTER COI 2015-16 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSD WMD POLICY NUMBER (MMIDDIVYYY) (MWYY) M/DD/ X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ A CLAIMS-MADE X OCCUR DAMAGE TO RENTED 1,000,000 PREMISES(Ea ocarrence) S _ OHY954250203 7/1/2015 7/1/2016 MEDEXP(Anyoneperson) $ 10,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 2,000,000 X POLICY TB: LOC PRODUCTS-COMP/OP AGG 5 2,000,000 OTHER: Employee Benefits S 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per acddent) S • X UMBRELLA UAB X OCCUR EACH OCCURRENCE 5 1,000,000_ A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTIONS OHY954250203 7/1/2015 7/1/2016 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT 5 OFFICER/MEMBER EXCLUDED? N I A • (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Certificate Holder is Additional Insured as Landlord of premises:165 Peconic Land, Peconic, NY • CERTIFICATE HOLDER CANCELLATION ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Att: Town Clerk ACCORDANCE WITH THE POLICY PROVISIONS. • P.O. Box 1179 Southold, NY 11971 AUTHORIZED REPRESENTATIVE Linda Godnick/DI ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025£7014011 • • •NYSIF® New York State Insurance Fund Workers'Compensation&Disability Benefits Specialists Since 1914 199 CHURCH STREET,NEW YORK,N Y 10007-1100 Phone:(888)997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 116024590 NORTH FORK ANIMAL WELFARE LEAGUE INC PO BOX 297 SOUTHOLD NY 11971 POLICYHOLDER CERTIFICATE HOLDER NORTH FORK ANIMAL TOWN OF SOUTHOLD WELFARE LEAGUE INC TOWN HALL MAIN ST PO BOX 297 SOUTHOLD NY 11971 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE Z 673 415-6 257023 08/23/2004 TO 06/01/2016 3/24/2015 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO 673 415-6 UNTIL 06/01/2016, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, .EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY IF SAID POLICY IS CANCELLED,OR CHANGED PRIOR TO 06/01/2016 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cerUcertval.asp or by calling(888)875-5790 VALIDATION NUMBER: 845985708 U-26.3 0/CD66903-21/23