HomeMy WebLinkAboutKingDanbyMicro_eSNAP_NYS Workers Compensation_20230210.pdf RecordID 27726 NEW Workers'
SYRK
TATE Compensation CERTIFICATE OF
Board NYS WORKERS COMPENSATION INSURANCE COVERAGE
1a.Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured
Bell Atlantic Mobile Systems, LLC 908-559-6176
d/b/a Verizon Wireless
1095 Avenue of the Americas 1c. NYS Unemployment Insurance Employer Registration Number of
New York NY 10036 Insured
26-70019
Work Location of Insured (Only required if coverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security
certain locations in New York State,i.e.,a Wrap-Up Policy) Number
RE:King Danbyy Micro(392588)Project Location:1100 Danby Road Ithaca,
New York 1485D. 22-2483217
2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) LM Insurance Corporation
Town of Ithaca 3b. Policy Number of Entity Listed in Box"l a"
Attn: Code Compliance
215 N.Tioga Street WA5-69D-550588-092
Ithaca NY 14850
3c.Policy effective period
6/30/2022 to 6/30/2023
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"T'insures the business referenced above in box 1a"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: Abby Nolan
(Pri ,d agent of insurance carrier)
Approved by: � 2/2/2023
(Signature) (Date)
Title:
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
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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
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