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(New. | Workers’
_ Safe | Comp ensation CERTIFICATE OF
Board NYS WORKERS’ COMPENSATION INSURANCE COVERAGE
of insured (use Steet address only) ~~ |1b. Business Telephone Number of insured — —
12. Leg@l Name g Agdrass
Developments Inc: | (585)265-2384
‘Sustain ade Ene WY.
-DBA GreenSpark Solar
176 East Main St.
‘Rochester, NY 14604 | 1c. NYS Unemployment Insurance Employer Registration Number of
: Insured
Work Lacation 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
'75-3038138
[a Ramsan Aaaressof Elly RequestingPoot of Coverage] 3a Nano hauranca
Carter ———~ National Union Fire Insurance Company
‘(Entity Being Listed as the Certificate Holder)
Town of Aurora 3b. Policy Number of Entity Listed In Box “4a”
575 Oakwood Ave. i'WC87087580
East Aurora, NY 14052
_| 3c. Policy effective period
: 3/1/2026... . © _ 3/1/2027
°['3d. The Proprietor, Partners or Executive Officers are
([] included. (Only check box if all partners/officers included)
[X] all excluded or certain partners/officers excluded.
in box"1a’ for workers
that the insurance carver indicated abo vé In box "3" ingures the business referenced abave
“This certifies
comp NsatioN. under the: PAGE
New ale Work com sation -aw, (Touse:th's form, New York (ny) Musthe listed under ten GA
onthe INFORMATION me agent
send
Wii RENO
this
tio INsurance poligy): The Insurance Carrieror tts Ikenged
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 fIcensed agent, or until the policy
expiration date listed in hox "3c", whichever is earlier.
This certificate is issued’as of information
@ Meijer’ rights UPON.ty
only: and conterse amend,
extend Or-attar the2 caverage
cavera afforgediby the:policy:listed, RO dogs jt Confer:ANY "OHts‘orras d: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 cancellationof y Indicated on thts form, itythi fies CONtinties to be
ate holder with a
proof that the business is com rijfic
‘Wamed
4 Contract issuedCoveb
on a permit, icense OFCompensation ificate authorized the pyeinege
holder, ‘ the re provige
pusiness myst ldesthat.ce
new Certificate of Workers’ r other
mandatory coverage requirements of the New York State Workers’ Compensation Law.
ggntative or licensed agent of the insurance carrier referenced
on this form.
TAGE OF NGUINCE carrig
Fh
Approved by: a = - aes “@ 6/1/2026
™ (Signature) ~ {Daley
T itle: Mernber
Telephone Number of authorized representative or licensed agent of insurance carrier: (585)872-5700
Please Note: Only insurance carriers and thelr licensed agents are authorized to issue Form C-106.2. Insurance brokers are NOT
authorized to issue it.
G-105.2 (9-17) Wwww.web.ny.gov