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HomeMy WebLinkAbout20190153 Wesley Antennae Replacement Insurances erj-IYORK IFation CERTIFICATE OF INSURANCE COVERAGE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier la.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured EMPIRE TELECOM USA, LLC 1150 1ST AVENUE, SUITE 600 484-804-4500 KING OF PRUSSIA, PA 19406 Work Location of Insured(Only required if coverage is specifically limited to lc. Federal Employer Identification Number of Insured certain locations in New York State,i.e., Wrap-Up Policy) or Social Security Number 46-0825383 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) City of Saratoga Springs Standard Security Life Insurance Company of New York 474 Broadway, Room 10 3b. Policy Number of Entity Listed in Box"la" Saratoga Springs, NY 12866 R05857-002 3c. Policy effective period 3/10/2013 to 12/13/2019 4. Policy provides the following benefits: O A. Both disability and paid family leave benefits. E I B. Disability benefits only. E I C. Paid family leave benefits only. 5. Policy covers: O A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. E I B. Only the following class or classes of employer's employees: Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as desc -d above. rA% �4 Date Signed 12/14/2018 By (Signature of insurance carrier's authoriz:d representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES IMPORTANT: If Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier, this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked, this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers' Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers' Compensation Board (Only if Box 4C or 56 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation Board, the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note: Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) I IIIIII IIIIIIIII IIIIIIIIIIIIIM DB-120.1 (10-17) Additional Instructions for Form DB-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in box"1a" for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in Box 2. The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is cancelled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from coverage indicated on this Certificate. (These notices my be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in Box 3c, whichever is earlier This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first, two thousand and twenty-one, the payment of family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first, two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. DB-120.1 (10-17) Reverse A�.�pL^a DATE(MM/DD/YYYY) 1,. CERTIFICATE OF LIABILITY INSURANCE 11/29/2018 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(ies) must have ADDITIONAL INSURED provisions or 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 NAME: Cassie Burke Arthur J. Gallagher Risk Management Services, Inc. PHONE FAX 856-675-1334 4000 Midlantic Dr, Suite 200 (A/C,No,Ext): (A/C,No):856-482-1888 Mt. Laurel NJ 08054 AD RIESS: CherryHiII.BSD.CertM@AJG.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:ACE American Insurance Company 22667 INSURED INSURER B: Liberty Mutual Fire Insurance Company 23035 Empire Telecom USA, LLC 1150 1st Avenue, Suite 600 INSURER C:AXIS Insurance Company 37273 King of Prussia, PA 19406 INSURER D: First Liberty Insurance Corporation 33588 INSURER E: Liberty Insurance Underwriters Inc 19917 INSURER F: COVERAGES CERTIFICATE NUMBER:782503174 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. ITR SPOLICY EFF POLICY EXP TYPE OF INSURANCE NSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS B X COMMERCIAL GENERAL LIABILITY TB2-631-510650-048 11/30/2018 11/30/2019 EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $300,000 X Contractual Liab MED EXP(Any one person) $5,000 X XCU PERSONAL&ADV INJURY $2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY X JERCOT X LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER: $ B AUTOMOBILE LIABILITY AS2-631-510650-038 11/30/2018 11/30/2019 COMBINED SINGLE LIMIT $2,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) C UMBRELLA LIAB X OCCUR Q-001-000073672-01 11/30/2018 11/30/2019 EACH OCCURRENCE $5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$25.000 $ D WORKERS COMPENSATION WC6-631-510650-018 11/30/2018 11/30/2019 X MTUTE OTH- AND EMPLOYERS'LIABILITY Y/N ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Cyber G25605457 003 11/30/2018 11/30/2019 Single Limit 1,000,000 E Excess Liability 1000324565-01 11/30/2018 11/30/2019 Each Occurrence 10,000,000 Aggregate 10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Property Policy Policy#13UUMBK0148 Policy Period: 11/30/18-11/30/19 Carrier: Hartford Fire Insurance Company Leased/Rented Equipment: Limit:$1,500,000 Deductible:$5,000 BPP Limit/Deductible:$8,265,000/$5,000 See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Saratoga Springs THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 474 Broadway, Room 10 ACCORDANCE WITH THE POLICY PROVISIONS. Saratoga Springs, NY 12866 AUTHORIZED REPRESENTATIVE V49' (94 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC#: AC L RL ADDITIONAL REMARKS SCHEDULE Page 1 of AGENCY NAMED INSURED Arthur J.Gallagher Risk Management Services, Inc. Empire Telecom USA, LLC 1150 1st Avenue,Suite 600 POLICY NUMBER King of Prussia, PA 19406 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Contractors Pollution Liability and Errors&Omissions Policy Policy#0311-0596 Policy Period: 11/30/2018-11/30/2019 Carrier:Allied World Assurance Company, Ltd. Occurrence/Aggregate:$5MM/10MM Hartford Fire Insurance Company Inland Marine Policy Eff Date: 11/30/18-Exp Date: 11/30/19 Policy#13UUMBK0148 Installation Operations-LIMIT:$5,000,000/DEDUCTIBLE:$5,000 In Transit-LIMIT:$1,000,000/DEDUCTIBLE: $5,000 In Temporary Storage-LIMIT:$15,000,000/DEDUCTIBLE:$5,000 Evidence of Insurance. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD EW " Workers' CERTIFICATE OF ATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured Empire Telecom USA, LLC 484-804-4500 1150 First Avenue, Suite 600 King of Prussia PA 19406 lc. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically limited to ld. Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 46-0825383 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) The First Liberty Insurance Corporation City of Saratoga Springs 3b. Policy Number of Entity Listed in Box"la" 474 Broadway Room 10 Saratoga Springs NY 12866 WC6-631-510650-018 3c.Policy effective period 11/30/2018 to 11/30/2019 3d.The Proprietor,Partners or Executive Officers are 0 included. (Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3" insures the business referenced above in box"1 a"for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York(NY) must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Linda Madden (PriLI__..• .___I L: f insurance carrier) Approved by: 11/29/2018 (Signature) (Date) Title: Senior Client Service Coordinator Telephone Number of authorized representative or licensed agent of insurance carrier: Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov 45581736 111/18-11/19 C105.2 1 Connie Myszka 111/29/2018 1:27:14 PM (CST) 1 Page 1 of 2 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-17) REVERSE 45581736 111/18-11/19 C105.2 1 Connie Myszka 111/29/2018 1:27:14 PM (CST) 1 Page 2 of 2