Monday, July 2, 2018

Verification




Arthur J. Gallagher House Inworth Road Feering Essex CO5 9SE T el: 01376 574200 Fax: 01376 574222 www.ajginternational.com Page 1 of 2 Arthur J. Gallagher Insurance Brokers Lim ited is authorised and regulated by the Financial Conduct Authority . Registered Office: Spectrum Building, 7 th Floor, 55, Bly thswood Street, Glasgow, G2 7AT. Registered in Scotland. Com pany Num ber: SC108909. To Whom It May Concern 24 th April 2018 Dear Sirs Our Client: R Swain & Sons , Gatwick Plant Ltd, Ebbsfleet Transport Ltd, Medway Haulage Ltd &/or Hallett Si l bermann Limited We are the Risk and Insurance Managers for the above clients and have pleasure in confirming details of their insurance arrangements as follows: Employers' Liability Insurer : Zurich Insurance Plc Policy No. : K202274812 Expiry Date : 30 th April 201 9 Limit of Indemnity any one occurrence : £10,000,000 Public / Products Liability Insurer : Zurich Insurance Plc Policy No. : K202274812 Expiry Date : 30 th April 201 9 Limit of Indemnity any one occurrence and in the annual aggregate in respect of Public Liability : £ 10 ,000,000 Indemnity to Principals for whom our clients are working : Included Excess Employers Liability Insurer : CNA Europe Policy No. : CCXOO/5141248 Expiry Date : 29 th April 201 9 Limit of Indemnity any one contract site : £ 10 ,000,000 over primary £10 ,000,000 Excess Public Liability Insurer : CNA Europe Policy No. : CCXOO/5141248 Expiry Date : 29 th April 201 9 Limit of Indemnity any one contract site : £ 1 0 ,000,000 over primary £5,000,000 Airside Public Liability Insured Insurer : : R Swain & Sons, Hallett Silbermann Ltd & Gatwick Plant Ltd Starr Insurance & Reinsurance Ltd Policy No. : RL0004515 Expiry Date : 30 th April 201 9 Limit of Indemnity any one occurrence Location of Airport covered : : £50,000,000 Any U.K Airport Extended Coverage Endorsement (Aviation Liabilities) AVN52G – Endorsement Number Four GBP 50,000,000 (or currency equivalent)(or the Combined Single Limit of Liability as shown above, whichever the lesser) any one occurrence and in the aggregate, being within the Combined Single Limit and not in addition thereto Page 2 of 2 Contractors Combined Insured I nsurer : : Gatwick Plant Ltd Zurich Insurance plc Policy No. : KV862950 Expiry Date : 30 th April 20 19 Contract Works Limit any one contract : £1,000,000 Hired - in Plant Limit : £2,000,000 Motor Trade Public / Servicing Liability Insured Insurer : : R Swain & Sons Ltd & Hallett Silbermann Ltd QBE Insurance (Europe) Ltd Policy No. : Y098559MTE Expiry Date : 30 th April 20 1 9 Limit of Indemnity any one occurrence : £2,000,000 Indemnity to Principals for whom our clients are working : Included Motor Fleet Insurer : QBE Insurance (Europe) Ltd Policy No. : Y065964FLT Expiry Date : 1 st November 201 8 Limits of Indemnity: - : a) Third Party Injury (all vehicles) Unlimited b) Third Party Property (cars) £20,000,000 c) Third Party Property (commercials) £5,000,000 This statement of cover extract has been prepared purely as confirmation of the insurance in force at the date of this letter which is subject to the terms and conditions of the insurance policy(ies). We accept no responsibility for any inadvertent or negligent act, error or omission on our part in preparing the statement or for any loss, damage or expense incurred by the recipient ar ising from reliance on the information given. We remain solely the agent of our Client and owe no legal duty or otherwise to any third party. Should the insurance cover be cancelled, assigned or changed in any way during the period of insurance neither w e nor insurers accept any obligation to notify any recipient. Yours faithfully, Brad Cotton Senior Account Handler Direct dial: 01376 574245 Email: brad_cotton@ajg.com

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NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF EARLY INTERVENTION COLLECTION OF INSURANCE INFORMATION DATE INSURANCE INFORMATION COLLECTED/UPDATED: *Is the Insurance Plan Regulated by New York State ? Yes No I f no, ha s the parent consented to use of their insurance benefits ? Yes No Is the Insurance Plan: Primary or Secondary Child's Name: Child's Date of Birth: Child's Gender: Parent/Guardian Name: Parent/Guardian Date of Birth: Parent/Guardian Phone No.: Insurance Company Name: Insurance Company Phone N o : ** Insurance Company Billing and Claiming Address: Insurance Plan /Policy Name: Type of Insurance Plan: Policy Holder Name: Policy Holder Date of Birth: Policy Holder Gender: Policy Holder Address: Policy Holder Phone Number: Policy Holder Relationship to Child: Policy Holder Employer Name: Employer Address: Employer Phone No.: Policy N o. for Billing: Child's Member Identification No : Group Number (if applicable) : Policy Effective From Date: Policy Effective To Date: Is the Plan Child Health Plus? Yes No Is the Plan Medicaid Managed Care? Yes No Is the P lan a self - funded plan? Yes No ** * Medicaid CIN Number ( 2 alpha, 5 numeric, 1 alpha) : CIN Effective From Date: CIN Effective To Date: Service Coordinator Name: Service Coordinator Phone N o : Service Coordinator Fax No. : Municipality Name: Service Coordinator Agency: Service Coordinator Address: NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF EARLY INTERVENTION COLLECTION OF INSURANCE INFORMATION (continued) NYEIS Child Reference #: Insurance Information reviewed at 6 month IFSP: date_________ initials ________ no changes ________ new form ________ Insurance Information reviewed at 12 month IFSP: date_________ initials ________ no changes ________ new form ________ Insurance Information reviewed at 18 month IFSP: date_________ initials ________ no changes ________ new form ________ Insurance Information reviewed at 24 month IFSP: date_________ initials ________ no changes ________ new form ________ Insurance Information reviewed: date_________ initials ______ __ no changes ________ new form ________
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