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Home My WebLink About2016 Aug 01 15 06:26p ellen hancock 6314778191 p.1 NYSIE New York State Insurance Fund 199 CHURCH STREET,NEW YORK,N.Y 10007-1100 (888)997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A n A A A A 116024590 NORTH FORK ANIMAL WELFARE LEAGUE INC RECEIVED PO BOX 297 SOUTHOLD NY 11971 APR 2 5 2016 POLICYHOLDER CERTIFICATE HOLDER NORTH FORK ANIMAL TOWN OF SOUTHOLD Southold Town Clerk 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 673415-6 257023 08/23/2004 TO 06/01/2017 04/15/2016 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 06/01/2017, 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 06101/2017 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/cert/certval.asp or by calling(888)875-5790 VALIDATION NUMBER 845985708 [��nli[u[nuu�um[UIUIL nwua>tunnonlul�llllplll1llll 11II1IIIIQ IIII00000000000030967528 1111 Form WC-CERT-NOPRINT Yerston I(03242014)[WC Palmy-034136] U-25 3 25Etm00000000003096752-03D001-oaDOWEa76441[Gt2a14359-05j[Cert_No=-CERT 1110'-00001]