HomeMy WebLinkAbouthighway fac contracts-20150709160009.pdf STATE OF NEW YDRK
WORKER&COMPENSATION BOARD
CERTIFICATE OF INSURANCE CO OE UNDER THE MYS DISABILITY BENEFITS LAW
PART 1.To be completed by Disa ility Benefits Carrier or Licensed Insurance Agent ofthat Carrier
la.Legal Name and Address of Insured(Use street address only) 1b.Business Telephone Number of Insured
D HILLMAN$SONS LLC (315)893-1836
3190 WESTLAND DRIVE
BOUCKVILLE,NY 13310 1c.NYS Unemployment Insurance Employer;Registration Number of
Insured
4858130
1d.Federal Employer Identification Number of Insured or Social Security
Number
223950814'
2.Name and Address of the Entity Requesting Proof of Coverage(Entity 3a.Name of Insurance Carrier
Being Listed as the Certificate Holder)
NATIONAL BENEFIT LIFE INSURANCE COMPANY
TOWN OF ENFIELD
168 ENFIELD`MAIN ROAD
ITHACA,NY 14850 3b.Policy Number of entity listed in box"1a":
8-910-0230977'
3c.Policy effective period:
04/01/2011 to 04/22/2013
4.Policy covers:
a. 4 All of the employer's employees eligible under the New York Disability Benefits Law,
b. j Only the following class or classes of the employer's employees:
Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carver referenced above and that the
named insured has NYS Disability Benefrts insurance coverage as described above.
Date Signed:04=2011 By 44,��
(Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent
of that insurance carrier)
Telephone Number:800-635-2711 Titile Vice President
IMPORTANT: If box"4a"is 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"is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the Disability Benefits Law.It
must be mailed for completion to the Workers'Compensation Board,DB Plans Acceptance Unit,20 Park Street,Albany,New
York 12207.
PART 2.To be completed by NYS Workers'Compensation Board(Only if box"4b"of Part 1 has been check
State 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
Benefits Law with respect to all of his/her employees.
Date Signed: By
(Signature of NYS Workers''Compensation Board Employee)
Telephone Number: Tible
Please Note:Only insurance carriers licensed to write NYS disability 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 (5-06)
Additional Instructions for Form S-120.
By signing this form,the insurance carrier identified in box"T'on this form is certifying that it is insuring the business referenced in box"la"for
disability benefits underthe New York State Disability Benefits Law.The Insurance Carrieror its licensed agent will send this Certificate of
Insurance to the entity listed as the certificate holder in box"2":This Cetf fiicate is valid forffie eariferofone year after Mks form is approved byUie
insurance carrier or its licensed agent or the policy expirshon date listed in box"3c".
Please Note:Upon the cancellation of the disability 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 Benefits
Coverage or other authored proof that the business is complying with the mandatory coverage requirements of the New York State Disability
Benefits Law.
DISABILITY BENEFITS LAW
Sec.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 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 for all employees has been secured as provided by this
article.
DB-120.1 (5-06)Reverse