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4.02 4.2 BIDS\AWARD Bid—Halfway Brook Trail Construction with 10%Contingency-3-9-2020 RESOLUTION AUTHORIZING AWARD OF BID FOR CONSTRUCTION OF HALFWAY BROOK TRAIL RESOLUTION NO. ,2020 INTRODUCED BY: WHO MOVED ITS ADOPTION SECONDED BY: WHEREAS, by Resolution No.: 107,2018 the Queensbury Town Board authorized establishment of the Halfway Brook Trail Capital Project Fund #223 to fund expenses associated with the final design and construction of the Halfway Brook Trail from Aviation Road to Peggy Ann Road(Project), and WHEREAS, by Resolution No.: 69,2020, the Town Board authorized and directed the Town's Purchasing Agent to publish an advertisement for bids for the Project as were more clearly specified in bid specifications prepared by the Town Supervisor and/or Town Purchasing Agent, and WHEREAS, General Municipal Law §103 requires that the Town advertise for bids and award the bid to the lowest responsible bidder meeting New York State statutory requirements and the requirements set forth in the Town's bid documents and specifications, and WHEREAS, the Purchasing Agent published such advertisement for bids and on February 28, 2020, duly received and opened all bids, and WHEREAS, the Town Supervisor and Purchasing Agent have recommended that the Town Board authorize the bid award to the lowest responsible bidder, Volt Landscape for the bid • amount of$112,400, and WHEREAS, there may be times when Change Orders may become necessary for such Project and therefore the Town Board wishes to provide the Town Supervisor with authorization to approve and sign certain Change Orders up to a ten-percent (10%) contingency ($11,240) for Change Orders that he deems necessary or appropriate, NOW, THEREFORE, BE IT RESOLVED, that the Queensbury Town Board hereby accepts and awards the bid for the construction of the Halfway Brook Trail from Aviation Road to Peggy Ann Road(Project) from the lowest responsible bidder, Volt Landscape, for the bid amount of$112,400, and BE IT FURTHER, RESOLVED, that the Town Board further authorizes and directs the Town Supervisor to execute any needed Agreement between the Town and Volt Landscape and/or any other needed documents related to the bid award and Project in form acceptable to the Town Supervisor, Town Budget Officer and/or Town Counsel, and BE IT FURTHER, RESOLVED, that the Town Board further authorizes the Town Supervisor to approve and sign Change Orders pertaining to such Project up to a ten-percent (10%) contingency or in the total amount not exceeding $11,240 that he deems necessary or appropriate, and BE IT FURTHER, RESOLVED, that the Town Board further authorizes and directs that payments for such Project shall be from the Halfway Brook Trail Capital Construction Account No.: 223-7110-2899 2 and the Town Board further directs that in the event there are funds remaining in such Capital Project Fund after completion of the Project or in the event that the Project is not undertaken, the moneys in the Capital Project Fund shall be returned to the Capital Reserve Fund No. 64, and BE IT FURTHER, RESOLVED, that the Town Board further authorizes and directs the Town Supervisor, Town Purchasing Agent, Town Budget Officer and/or Town Counsel to take any and all action necessary to effectuate the terms of this Resolution. Duly adopted this 9th day of March, 2020, by the following vote: AYES : NOES : ABSENT: 3 BID OPENING RESULTS FOR: Halfway Brook Trail Project February 28, 2020 Bid Opening 2:00 PM Purchasing Agent: Joanne Watkins Witnessed by:John Strough COMPANY NAME& BID AMOUNTS IRAN DIVESTMENT NON- ADDRESS COLLUSIVE BID CERT NEW CASTLE PAVING LLC $262,200 YES YEA TROY,NY TRINITY CONSTRUCTION INC $445,393 YES YES SELKIRK,NY GALLO CONSTRUCTION CORP $132,900 YES YES WATERVLIET,NY VOLT LANDSCAPE $112,400 YES YES QUEENSBURY,NY VII. BID PROPOSAL To: TOWN OF QUEENSBURY: 1. The undersigned hereby declares that he/she is the only person interested in this Bid; that it is made without any connection with any person making another Bid for the same contract; that the Bid is in all respects fair and without collusion or fraud; and that no official of the Town,or any person in the employ of the state, is directly or indirectly interested in the Bid or in the supplies or work to which it relates,or in any portion of the profits thereof 2. The undersigned also declares that he/she has carefully examined the annexed form of Bid documents and specifications and will provide the following item at the prices indicated, immediately upon request,to be fully paid within 30 days of receipt by the Town. ec 3. Halfway Brook Trail Project: PRICE: $ //2, /OOO r 4. CONTRACT-AGREEMENT: By execution of this Bid Proposal,Bidder agrees to execute a further agreement if requested by the Town of Queensbury and agrees, in any event, that all understandings, conditions, provisions and specifications referred to in and a part of this Bid Proposal, the Notice to Bidders, the Instructions to Bidders, the Specifications, the Affidavit of Non- Collusion, and the Certification of Compliance with the Iran Divestment Act shall constitute the terms and conditions of an agreement and actually be an agreement, if no other agreement is entered into,between the Bidder and the Town of Queensbury. r"--7 DATE *SIGNATURE OF AUTHORIZED COMPANY OFFICIAL-PRINT NAME NEXT TO SIGNATURE COMPANY NAME x /5-7 Si.,�9,--t/Si .0- k.) az.e.,,s az COMPANY ADDRESS SW—. '773 — s(`iy fir—.)a/— Nit COMPANY PHONE NUMBS 27 VI. AFFIDAVIT OF NON-COLLUSION I, h3�-R+ C•w� , being duly sworn, do depose and state: 1. That in connection with this procurement, (A) The prices in this bid have been arrived at independently, without consultation, communication, or agreement, for the purpose of restricting competition, as to any matter relating to such prices with any other bidder or with any competitor;and (B) The prices which have been quoted in this bid have not been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to opening directly or indirectly to any other bidder or to any competitor; and (C) No attempt has been made or will be made by the bidder to induce any other person or firm to submit or not to submit a bid for the purpose of restricting competition. 2. The undersigned further states: (A) Affiant is the person in the bidder's organization responsible within that organization for the decision as to the prices being bid herein and that Affiant has not participated, and will not participate, in any action contrary to(1)(A)through(1)(C)above;or (B) (1) Affiant is not the person in the bidder's organization responsible within that organization for the decision as to the prices being bid herein but that Affiant has been authorized in writing to act as agent for the persons responsible for such decision in certifying that such persons have not participated, and will not participate, in any action contrary to (1) (A) through (1) (C) above,and as their agent does hereby so certify; and 25 (2) Affiant has not participated and will not participate, in any action contrary to(1)(A)through(1)(C)above. 3. It is expressly understood that the foregoing statements, representations, and promises are made as a condition to the right of the bidder to receive payment under any award made hereunder. ---- -- L' Signed Subscribed and sworn to before me this o7tCday of 0 0-6. _ /1l � ��u5 b f ES . .,J-CUNA . _ry Public,State of New Yor4: Warren Co.#0el-sJu y 04200 d Commission Exp 26 • VIII. THE IRAN DIVESTMENT ACT CERTIFICATION OF COMPLIANCE WITH THE IRAN DIVESTMENT ACT As a result of the Iran Divestment Act of 2012(the"Act"), Chapter 1 of the 2012 Laws of New York, a new provision has been added to State Finance Law(SFL)§ 165-a and New York General Municipal Law§ 103-g, both effective April 12, 2012. Under the Act, the Commissioner of the Office of General Services (OGS)will be developing a list of"persons"who are engaged in"investment activities in Iran"(both are defined terms in the law)(the"Prohibited Entities List"). Pursuant to SFL§ 165-a(3)(b), the initial list is expected to be issued no later than 120 days after the Act's effective date at which time it will be posted on the OGS website. By submitting a bid in response to this solicitation or by assuming the responsibility of a Contract awarded hereunder, each Bidder/Contractor, any person signing on behalf of any Bidder/Contractor and any assignee or subcontractor and, in the case of a joint bid, each party thereto, certifies, under penalty of perjury, that once the Prohibited Entities List is posted on the OGS website, that to the best of its knowledge and belief, that each Bidder/Contractor and any subcontractor or assignee is not identified on the Prohibited Entities List created pursuant to SFL§ 165-a(3)(b) Additionally, Bidder/Contractor is advised that once the Prohibited Entities List is posted on the OGS Website, any Bidder/Contractor seeking to renew or extend a Contract or assume the responsibility of a Contract awarded in response to this solicitation must certify at the time the Contract is renewed, extended or assigned that it is not included on the Prohibited Entities List. During the term of the Contract, should the Town receive information that a Bidder/Contractor is in violation of the above-referenced certification, the Town will offer the person or entity an opportunity to respond. If the person or entity fails to demonstrate that he/she/it has ceased engagement in the investment which is in violation of the Act within 90 days after the determination of such violation,then the Town shall take such action as may be appropriate including, but not limited to, imposing sanctions, seeking compliance, recovering damages or declaring the Bidder/Contractor in default. The Town reserves the right to reject any bid or request for assignment for a Bidder/Contractor that appears on the Prohibited Entities List prior to the award of a contract and to pursue a responsibility review with respect to any Bidder/Contractor that is awarded a contract and subsequently appears on the Prohibited Entities List. , being duly sworn, deposes and says that he/she is the cs-`0 — of the ��tA �Tup'_ Corporation. By submission of this bid, each bidder and each person signing on behalf of any bidder certifies, and in the case of a joint bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of its knowledge and belief that each bidder is not on the list created pursuant to paragraph(b)of subdivision 3 of§165-a of the State Finance Law. SIGNED SWORN to before me this day ofC0Of�-�-E��20C� JESS LACUNA Notary Public,State of New York Warren Co.#01 LA6170455 Notary Public: Commission Expires July 9,20.. 28 • AC R e CERTIFICATE OF LIABILITY INSURANCE DATE{MMIDD/YYYY) 02/26/2020 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 POUCIES 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 CCO TACT House Hughes Insurance Agency,Inc. PHONE o.Ed). (518)793 3131 I ppvc,Nob (518)793-3121 328 Bay Road ADORESS: PO BOX 4630 INSURER(S)AFFORDING COVERAGE NAIC S Queensbury NY 12804 INSURER A: Selective Ins.Co.of America 12572 INSURED INSURER B: Hartford Property&Casualty 34690 VOLT LANDSCAPE&IRRIGATION CO,INC INSURER C: 159 SUNNYSIDE RD INSURER D: INSURER E: QUEENSBURY NY 12804-7762 INSURER F: COVERAGES CERTIFICATE NUMBER: 19-20 Master 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN3lt' ADDLSUBR POLICY err POLICY EXP TYPE OF INSURANCE LTR INSD WVD POLICY NUMBER (MMIDDIYYYY) (MM/DD/YYYY) UNITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 DAMAGE TO RENTED 500 CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ '000 — MED DIP(Any one person) S 15,000 A $ 2069939 08/192019 08/19/2020 PERSONAL&ADV INJURY S 1,0'0 GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 3'�'�0 RPOLICY®TIE& LOC PRODUCTS-COMP/OPAGG S 3,000.000 OTHER: S AUTOMOBILE UABILRY COMBINED SINGLE UNIT s 1,000.000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) S A OWNED SCHEDULED S 2069939 08/19/2019 08/19/2020 BODILY INJURY(Per accident) S AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I I RETENTION S S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ATUTE I ER B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA 01VVECLQ1839 09/15/2019 09/15/2020 EL EACH ACCIDENT S 100.000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 100' (4 If yes,deSaibe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY UN T S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Subject to all policy terms,limitations and conditions: Certificate Holder is Additional Insured when required by written contract,agreement or permit. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Glens Falls ACCORDANCE WITH THE POLICY PROVISIONS. 42 Ridge Street AUTHORIZED REPRESENTATIVE Glens Falls NY 12801 t cp i ©1988 2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured Volt Landscape&Irrigation Co.,Inc. (518)793-5899 159 Sunnyside Road Queensbury,NY 12804 lc.NYS Unemployment Insurance Employer Registration Number of Insured ld.Federal Employer Identification Number of Insured Work Location of Insured(Only required f coverage is specifically or Social Security Number limited to certain locations in New York State, Le., a Wrap-Up 141819435 Policy) 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Hartford Property&Casualty 3b.Policy Number of entity listed in box"la" City of Glens Falls 01WECLQ1639 42 Ridge Street Glens Falls,NY, 12801 3c. Policy effective period 9/15/2019 to 9/15/2020 3d. The Proprietor,Partners or Executive Officers are included. (Only check box if all partners/ofcers Included) X 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"la" 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 will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums 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. Please Note: Upon the 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 Abodeely (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ��. 7h _f� 11 February 26, 2020 (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 518-793-3131 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(9-07) www.wcb.state.ny.us 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 (9-07)Reverse • o CERTIFICATE OF LIABILITY INSURANCE DATE 2l 0" 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 POUCIES 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 House Hughes Insurance Agency,Inc. P►IONE (518)7933131 I FnKx 18 793-3121 �AIC.No.Fxtl: fA .No): � ) 328 Bay Road ADDRESS: PO BOX 4630 INSURER(S)AFFORDING COVERAGE NAIL a Queensbury NY 12804 INSURER A: Selective Ins.Co.of America 12572 INSURED INSURER B: Hartford Property&Casualty 34690 VOLT LANDSCAPE&IRRIGATION CO,INC INSURER C: 159 SUNNYSIDE RD INSURER D: INSURER E: QUEENSBURY NY 12804-7762 INSURER F: COVERAGES CERTIFICATE NUMBER: 19-20 Master 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. INLTR SR TYPE OF INSURANCE ADDU5UBR POUCY EFP POLICY MPiNSD WVD POLICY NUMBER _IMMIDD/YYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE 1 7 OCCUR PREMDAMISES SES(Es occurrence) $ _ MED EXP(Am/one person) $ 15,000 A S 2069939 08/19/2019 08/19/2020 PERSONAL&ADV INJURY $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3�� RPOLICY®JECaT LOC PRODUCTS-COMP/OP AGG $ 3.000.000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A `—' OWNED —SCHEDULED S 2069939 08/19/2019 08/19/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE y AUTOS ONLY _ AUTOS ONLY (Per accident) S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION S $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABIUTY STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y� NIA 01 WECLQ1639 09/15/2019 09/15/2020 EL.EACH ACCIDENT S 100, OFFICER 000 /MEMBER EXCLUDED? (Mandatory In NH) EL.DISEASE-EA EMPLOYEE $ 100,000 It yes.des rte under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY UNIT $ 50t1,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Subject to all policy terms,limitations and conditions: Certificate Holder is Additional Insured when required by written contract,agreement or permit. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Queensbury ACCORDANCE WITH THE POLICY PROVISIONS. 742 Bay Rd AUTHORIZED REPRESENTATIVE Queensbury NY 12804 / c,.c„ i ®1888-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured Volt Landscape&Irrigation Co.,inc. (518)793-5899 159 Sunnyside Road Queensbury,NY 12804 lc.NYS Unemployment Insurance Employer Registration Number of Insured ld.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically or Social Security Number limited to certain locations in New York State, i.e., a Wrap-Up 141819435 Policy) 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Hartford Property&Casualty 3b.Policy Number of entity listed in box"la" Town of Queensbury 01WECLQ1639 742 Bay Rd Queensbury,NY, 12804 3c. Policy effective period 9/15/2019 to 9/15/2020 3d. The Proprietor,Partners or Executive Officers are included. (Only Bieck box if all pattners/officeis Included) X 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"la" 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 will also notify the above certificate holder within 10 days IFa policy is canceled due to nonpayment ofpremiums 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. Please Note: Upon the 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 Abodeely (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 71_l,4„ �� C! February 26, 2020 (Signature) ' (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 518-793-3131 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(9-07) www.wcb.state.ny.us 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 (9-07) Reverse