CERTIFICATE OF LIABILITY INSURANCE
DGABU-1
OP ID: E6 DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
07/28/2016
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 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). CONTACT Janine Miceli NAME: PHONE (A/C, No, Ext): 585-232-4424 E-MAIL ADDRESS:
PRODUCER
Brown & Brown of New York, Inc 45 East Avenue Rochester, NY 14604 Andy Meloni
FAX (A/C, No):
585-232-5813
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A : Travelers INSURED
Indemnity Co of Amer INSURER B : Travelers Indemnity Co INSURER C : Merchants Mutual Insurance Co INSURER D : Phoenix Insurance Co.
DGA Builders LLC DGA Builders Inc. DGA Equipment LLC DGA Construction Group LLC 1170 Pitts-Victor Rd. suite100 Pittsford, NY 14534
COVERAGES
25666 25658 25623
INSURER E : INSURER F :
CERTIFICATE NUMBER:
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 LTR
A
TYPE OF INSURANCE
X
ADDL SUBR INSD WVD
POLICY NUMBER
POLICY EFF POLICY EXP (MM/DD/YYYY) (MM/DD/YYYY)
COMMERCIAL GENERAL LIABILITY CLAIMS-MADE
X
OCCUR
DT-CO-168M3370-TIA-16
X
01/01/2016 01/01/2017
GEN'L AGGREGATE LIMIT APPLIES PER: PROPOLICY X JECT LOC
AUTOMOBILE LIABILITY
C
X ANY AUTO OWNED X ALL X SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON-OWNED AUTOS $1000 coll X $50 comp. X X OCCUR X UMBRELLA LIAB EXCESS LIAB
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
PRODUCTS - COMP/OP AGG
$
Emp Ben.
OTHER:
B
LIMITS EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence)
DT-810-168M33370-TIL-16
01/01/2016 01/01/2017
$
$
COMBINED SINGLE LIMIT (Ea accident)
$
BODILY INJURY (Per person)
$
1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000 1,000,000 1,000,000
BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident)
$ $
CUP0000940
CLAIMS-MADE
01/01/2016 01/01/2017
10,000 X RETENTION $ DED WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE N/A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below D Inland Marine
EACH OCCURRENCE
$
AGGREGATE
$
10,000,000 10,000,000
$ PER STATUTE
OTHER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT
QT-660-627OR108-PHX
01/01/2016 01/01/2017 Leased/re
Ded
$
150,000 1,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
RE: DGA Job #16-055 Woodland Acres Morgan Woodland Acres, LLC & Morgan Management, LLC are listed as additional insured when required by executed written contract.
CERTIFICATE HOLDER
CANCELLATION
MORGWOO Morgan Woodland Acres, LLC 1080 Pittsford Victor Rd Pittsford, NY 14534
ACORD 25 (2014/01)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE
© 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD
NYSIFO New York State Insurance Fund R
Workers' Compensation & Disability Benefits Specialists Since 1914 199 CHURCH STREET, NEW YORK, N.Y. 100071100 Phone: (888) 9973863
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
^ ^ ^ ^ ^ ^ 453663244 LOVELL SAFETY MGMT CO., LLC 110 WILLIAM STREET 12TH FLR NEW YORK NY 10038 Scan to Validate
POLICYHOLDER
CERTIFICATE HOLDER
DGA BUILDERS LLC 1170 PITTSFORD VICTOR ROAD SUITE 100 PITTSFORD NY 14534 POLICY NUMBER G2175 2837
CERTIFICATE NUMBER 565013
MORGAN WOODLAND ACRES, LLC 1080 PITTSFORDVICTOR ROAD PITTSFORD NY 14534
PERIOD COVERED BY THIS CERTIFICATE 04/01/2016 TO 04/01/2017
DATE 7/28/2016
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2175 2837 UNTIL 04/01/2017, 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. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 04/01/2017 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 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 POLICY AFFORDS COVERAGE TO THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. MICHAEL SZUROMI GREGORY CRAIG EDWARD RAYNOR THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS' COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED.
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
U26.3
This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 8755790 VALIDATION NUMBER: 36162823
OP ID: E6 DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
07/28/2016
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 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). CONTACT Janine Miceli NAME: PHONE (A/C, No, Ext): 585-232-4424 E-MAIL ADDRESS:
PRODUCER
Brown & Brown of New York, Inc 45 East Avenue Rochester, NY 14604 Andy Meloni
FAX (A/C, No):
585-232-5813
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A : Travelers INSURED
Indemnity Co of Amer INSURER B : Travelers Indemnity Co INSURER C : Merchants Mutual Insurance Co INSURER D : Phoenix Insurance Co.
DGA Builders LLC DGA Builders Inc. DGA Equipment LLC DGA Construction Group LLC 1170 Pitts-Victor Rd. suite100 Pittsford, NY 14534
COVERAGES
25666 25658 25623
INSURER E : INSURER F :
CERTIFICATE NUMBER:
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 LTR
A
TYPE OF INSURANCE
X
ADDL SUBR INSD WVD
POLICY NUMBER
POLICY EFF POLICY EXP (MM/DD/YYYY) (MM/DD/YYYY)
COMMERCIAL GENERAL LIABILITY CLAIMS-MADE
X
OCCUR
DT-CO-168M3370-TIA-16
X
01/01/2016 01/01/2017
GEN'L AGGREGATE LIMIT APPLIES PER: PROPOLICY X JECT LOC
AUTOMOBILE LIABILITY
C
X ANY AUTO OWNED X ALL X SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON-OWNED AUTOS $1000 coll X $50 comp. X X OCCUR X UMBRELLA LIAB EXCESS LIAB
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
PRODUCTS - COMP/OP AGG
$
Emp Ben.
OTHER:
B
LIMITS EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence)
DT-810-168M33370-TIL-16
01/01/2016 01/01/2017
$
$
COMBINED SINGLE LIMIT (Ea accident)
$
BODILY INJURY (Per person)
$
1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000 1,000,000 1,000,000
BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident)
$ $
CUP0000940
CLAIMS-MADE
01/01/2016 01/01/2017
10,000 X RETENTION $ DED WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE N/A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below D Inland Marine
EACH OCCURRENCE
$
AGGREGATE
$
10,000,000 10,000,000
$ PER STATUTE
OTHER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT
QT-660-627OR108-PHX
01/01/2016 01/01/2017 Leased/re
Ded
$
150,000 1,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
RE: DGA Job #16-055 Woodland Acres Morgan Woodland Acres, LLC & Morgan Management, LLC are listed as additional insured when required by executed written contract.
CERTIFICATE HOLDER
CANCELLATION
MORGWOO Morgan Woodland Acres, LLC 1080 Pittsford Victor Rd Pittsford, NY 14534
ACORD 25 (2014/01)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE
© 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD
NYSIFO New York State Insurance Fund R
Workers' Compensation & Disability Benefits Specialists Since 1914 199 CHURCH STREET, NEW YORK, N.Y. 100071100 Phone: (888) 9973863
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
^ ^ ^ ^ ^ ^ 453663244 LOVELL SAFETY MGMT CO., LLC 110 WILLIAM STREET 12TH FLR NEW YORK NY 10038 Scan to Validate
POLICYHOLDER
CERTIFICATE HOLDER
DGA BUILDERS LLC 1170 PITTSFORD VICTOR ROAD SUITE 100 PITTSFORD NY 14534 POLICY NUMBER G2175 2837
CERTIFICATE NUMBER 565013
MORGAN WOODLAND ACRES, LLC 1080 PITTSFORDVICTOR ROAD PITTSFORD NY 14534
PERIOD COVERED BY THIS CERTIFICATE 04/01/2016 TO 04/01/2017
DATE 7/28/2016
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2175 2837 UNTIL 04/01/2017, 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. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 04/01/2017 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 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 POLICY AFFORDS COVERAGE TO THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. MICHAEL SZUROMI GREGORY CRAIG EDWARD RAYNOR THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS' COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED.
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
U26.3
This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 8755790 VALIDATION NUMBER: 36162823
