Text · page 23 of 36
Read the whole document on one page (all 36 pages, each with its own heading)
This document was a scan. Its text was produced by character recognition and may contain errors; check the original for exact wording.
new | Workers” YORK Workers’ in ~ state | Cormpensation. CERTIFICATE OF INSURANCE COVERAGE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1. To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a. Legal Name & Address of Insured (use street address only) 1b. Business Telephone Number of Insured GREENSPARK SOLAR 585 350 5608 318 TIMOTHY LANE ONTARIO, NY 14519 1c. Federal Employer Identification Number of Insured Work Location of Insured (Only required if coverage is specifically limited to or Social Security Number certain locations in New York State, i.e., Wrap-Up Policy) 753038138 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) First Unum Life Insurance Company Town of Aurora 3b. Policy Number of Entity Listed in Box "1a" 575 Oakwood Avenue, 942879 East Aurora, NY 14052 3c. Policy effective period 06/01/2026 to 06/01/2027 4. Policy provides the following benefits: A. Both disability and paid family leave benefits. [| B. Disability benefits only. [] C. Paid family leave benefits only. 5, Policy covers: A. All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. ] B. Only the following class or classes of employer's employees: Under penalty of perjury, | certify that | am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. signed by Madelyn Patton Date Signed 06/01/2026 sy Madelyn Patton ‘Madelyn Patton, [email protected] 4am tha author of this document ate‘'2026,08.01 14:38:36-04'00' 4222 eal B56 (Signature of insurance carrier's authorized representati or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 1-800-ASK-UNUM Name and Tite Madelyn Patton DBL Specialist IMPORTANT: If Boxes 4A and 5A are 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, 4C or 5B is checked, this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers' Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2. To be completed by the NYS Workers' Compensation Board (Only if Box 4C or 5B of Part 1 has been checked) State of 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 and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers' Compensation Board Employee} Telephone Number Name and Title Please Note: Only insurance carriers licensed to write NYS disability and paid family leave 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 (10-17) TT