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HomeMy WebLinkAbout2017 New,Yq fk State Insurance Fund 1991CHURCH STREET,NEW YORK,N.Y. 10007-1100 (888)997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE RECEIVED ^A A A A A 116024590 NORTH FORK ANIMAL WELFARE LEAGUE INC JA N 3 1 2017 PO BOX 297 SOUTHOLD NY 11971 Southold Town Clerk POLICYHOLDER CERTIFICATE_HOLDER NORTH FORK ANIMAL TOWN OF SOUTHOLD WELFARE LEAGUE INC TOWN CLERK PO BOX 297 PO BOX 9179 SOUTHOLD NY 11971 SOUTHOLD NY 11971 POLICY NUMBER I CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE Z 673 415-6 628764 08/23/2006 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 06/01/2017 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:/Iwww.nysif.com/certtcertval.asp or by calling(888)875-5790 VALIDATION NUMBER: 291985507 I[u�I�IpI 101110N11111fi1111I0ll�0000000001111 uI Fom WC-CERT-NOPRINT Version 1(03242014)[WC Policy-6734156] U-26 3 27 [00000000000030967530](0001-000004607644][##Z]I14359-05HCert NoP-CERT 1][01-000011 DATE(MMIODNYYY) A400RDO® CERTIFICATE OF LIABILITY INSURANCE 7/12016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.TH15 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(ies)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). CONT Harmony Reina PRODUCER NAME: Animal Welfare Organization Insurance Program LLC HCNo : (717)630-1030 ac No:(717)630-1188 E-MAIL garmony@awoiglonline.com 195 Stock Street, Suite 118 ADDRESS: P.O. Box 933 IMURFRISI AFFORDING COVERAGE NAIL# Hanover PA 17331 INSURER AAmTruSt North America INSURED - INSURER B: North Fork Animal Welfare League, Inc. INSURERC: 165 Peconic Lane INSURER D: INSURER E- Peconic NY 11958 INSURER F: COVERAGES CERTIFICATE NUMBER:CL167123470 REVISION NUMBER: INDICATED.THIS 13 T ICY PERIOD CNOTTWITHSTANDING AIIYIREQUIREMEES OF NTNTERM ORCE DCOND TION OF ANY CONTRACHAVE BEEN ISSUED O OR OTHER DOCUMENT WITH RESPECT TOTHE INSURED NAMED ABOVE FOR THE LWHICH 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 P PAID DICY CLAIMS. LIMITS INSR ADDL SUER POLICPOLICY NUMBER MIDD MIDD TYPE OF INSURANCE D D 1,000,000 EACH OCCURRENCE 5 X COMMERCIAL GENERAL LIABILITY 0 TO RENTED 100,000 CLAIMS-MADE �OCCUR PREMISES Ea occurrence $A 7/1/2016 7/1/2017 MEDECP(Any one persan) S 5,000 }( S9PP1154894 0 PERSONAL&ADV INJURY S 1,000,00GENERAL AGGREGATE S 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG S 3,000,000 X POLICY JECOT_ El LOC Professional Liability $ 1,000,000 OTHER- COMBINED SINGLE LIMIT S Ea accident) — AUTOMOBILE LIABILITY BODILY INJURY(Per person) S ANY AUTO BODILY INJURY(Per accident) S ALL OWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE S NON-OWNED Per awdent HIRED AUTOS AUTOS S EACH OCCURRENCE $ 1 000 000 X UMBRELLA LIABOCCUR AGGREGATE S A EXCESS LIAB H CLAIMS-MADE WOpI1154486 7/1/2017 7/1/2010 S DED X I RETENTIONS 10 000 PER OTH- WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY YIN E.L EACH ACCIDENT S ANY P OPRIETERIPARTNDED4 ERJEXECUTIVE ❑NIA E.L.DISEASE-EA EMPLOYE S OFF(Mandatory In NH) E If yes,descnbe under L DISFJISE-POLICY LIMIT 5 DESCRIPTION OF OPERA710NS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Additional Insured Clause in favor of Certificate Holder in regards to location 165 Peconic Lane, Peconic, NY. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE IMLL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold-, NY 11971 AUTHORIZED REPRESENTATIVE Brian Barrick/HR ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 OnUnn ACC)REN® CERTIFICATE OF LIABILITY INSURANCE °8��/zo1N7 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAAMEAC Harmony Reins. Animal Welfare Organization Insurance Program LLC PHONE (717)630-1030 No:(717)630-1188 195 Stock Street, Suite 118 AMESS:Harmony®awoiponline.com a P.O. BOX 933 INSURE S AFFORDING COVERAGE NAIC# Hanover PA 17331 INSURER A:AmTrus t North America INSURED INSURER B: North Fork Animal Welfare League, Inc. INSURERC: POB 297 INSURERD. INSURER E Southold NY 11971 INSURER F: COVERAGES CERTIFICATE NUMBER:CL178426623 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 ILTR TYPE OF INSURANCE BPOLIPOLICY NUMBER MMMfDD EFF MP�p EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 AMAGE TO RENTED A CLAIMS-MADE ❑X OCCUR PREMSES Esoccu nce $ 100,000 X WPP1154894 01 7/1/2017 7/1/2018 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 11000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000,000 X POLICY PRO ❑LOC JECT PRODUCTS-COMPIOPAGG $ 3,000,000 OTHER Professional Liability $ 11000,000 AUTOMOBILE LIABILITY COMB NED SINGLE LIMB $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS UTOS NPROPERTY DAMAGE HIRED AAUUTOSTOS ED $ Per.ccident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED) FINIA (Mandatory In NH) E L DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ P IVED DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Additional Insured Clause in favor of Certificate Holder. NOV 2 1 2017 Southold Town Clerk 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 PO BOX 1179 ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHORIZED REPRESENTATIVE Brian Barrick/HR ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) knNew York State Insurance Fund trm"', Workers'Compensation&Disability Benefits Specialists Since 1914 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) RECEIVED 0 '0 ^"^^A^ 116024590 NOV 2 1 2017 NORTH FORK ANIMAL i WELFARE LEAGUE INC PO BOX 297 '� SOUTHOLD NY 11971 5®uthold Town Clerk 0� Scan to Validate POLICYHOLDER CERTIFICATE HOLDER NORTH FORK ANIMAL TOWN OF SOUTHOLD WELFARE LEAGUE INC TOWN CLERK PO BOX 297 PO BOX 1179 SOUTHOLD NY 11971 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATENUMBER POLICY PERIOD DATE Z 673 415-6 39226$ 06/01/2017 TO 06/01/2018 11/21/2017 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 673 415-6, 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 YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:IAN MN.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. 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 VALIDATION NUMBER:64969576 U-26.3