Preview
FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM INDEX NO. 155973/2017
NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
EXHIBIT A
FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM INDEX NO. 155973/2017
NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
Nationwide'
Certification
I,Ebone M Lewis, as a duly authorized National Casualty Cornpany associate entrusted with
oversight of the system of record from which this copy was produced, based upon information
and belief, certify under the penalty of perjury that this attached copy of CAO7769578,
05/28/2017 to 05/28/2018 was made at or near the time of certification, as part of regularly
conducted business activities, and is a true and accurate copy of the official record kept as
part of regular business activities.
October 16. 2020
Ógnature Date
EBONE M LEWIS
Print Name
CL Lead Processor
Title
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FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM
NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
ADDENDUM
Some internal notes, stamps or typing on the Declaration
sheet may appear. The intended use for these is internal
only and may not have been a part of the policy received
by the insured.
Policy fees, inspection fees or taxes, or additional
instructional stamps may have appeared on the policy
received by the insured but may not appear on this copy.
(Page 3 of 66) INDEX NO. 155973/2017
FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM
NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
National Casualty Company
NOTICE TO POLICYHOLDERS-
REDOMESTICATION OF NATIONAL CASUALTY COMPANY TO OHIO
On October 1, 2016, National Casualty Company moved itsdomicile from Wisconsin to Ohio. Itremains
licensed to do insurance business in Wisconsin. Aside from the formal relocation of itsdomicile, there will
be no change in any other relationship concerning your insurance with us. Allcompany contacts coilceriliilg
claims, collection of premiums and policyholder services remain unchanged.
If youhave any questions about this,please contact your agent.
NOTN0583CW (10-16)
(Page 4 of 66) INDEX NO. 155973/2017
FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM
NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
Nationwide®
Underwritten by: National Casualty Company
Home Office:8877 Nodh Center Drive • Scottsdale, Arizona 85258
Gainey
Administrative Office: 8877 North Gainey Center Drive •Scottsdale, Arizona 85258
1-800-423-7675 • A Stock Company
NOTICE:
THESE POLICY FORMS AND THE APPLICABLE RATES ARE
EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK
INSURANCE LAW AND REGULATIONS. HOWEVER, THE FORMS
AND RATES MUST MEET THE MINIMUM STANDARDS OF THE
NEWYORKINSURANCELAWANDREGULATIONS.
CLASS1
InWitness Whereof, the Company has caused this policy to be executed and attested.
Secretary President
The information contained herein replaces any similar information contained elsewhere in thepolicy.
UT-COVPG-NY (1-16)
(Page 5 of 66) INDEX NO. 155973/2017
FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM
NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
Nationwide'
Scottsdale Insurance Company
National Casualty Company
Scottsdale !ndemnny Company
Scottsdale Surplus Lines Insurance Company
CLAIM REPORTING INFORMATION
Your insurance has been placed with a Nationwide® insurance company.
policy
Our commitment to you is to provide fast, fairclaim service. Piciliptly reporting an event that could lead to
a claim, as required by your policy, helps us fulfill
this commitment to you. Please refer to your policy for
thisand allother terms and conditions.
To report a claim, you may contact us 24 hours a day, 7 days a week, by calling 1-800-423-7675 or via our
website at www.nationwideexcessandsurplus.com.
Thank you foryour business and as always, we appreciate the opportunity to serve you.
HOW TO REPORT A CLAIM
Call 1-800-423-7675 or visit
our website at www.nationwideexcessandsurplus.com.
In order to expedite thisprocess, please be prepared to furnish as much of the following information as
possible:
• Your number
policy
• Date, time and location of the loss/accident
• Details of the loss/accident
• address and phone number of involved parties
Name, any
• If applicable,name of law enforcement or firedepartment with the incident number
agency along
Please refer to your policy for spec!!!c claim reporting myüirsrasiits.
NOTX0178CW (3-16)
(Page 6 of 66) INDEX NO. 155973/2017
FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM
NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
COMMON POLICY DECI..ARATIONS .
NEW National Casualty Company PolicyNumber
Renewal ofNumber Home Office: CAO776957 8
Madison, Wisconsin
AdministrativeOffice:
8877 NorthGainey Center Driveo Senttsde!e, Arizona 85258
1-800-423-7675
ASTOCK COMPANY
ITEM 1. Named Insured and Mailing Address
PORT MORRIS TILE & MARBLE, LLP
1285 OAKPOINT AVENUE
BRONX NY 10474
Agent Name and Address
-
CRC INSURANCE SERVICES INC Agent No.: Program No.: NONE
105 EISENHOWER PKWY FL 4
29718
ROSELAND NJ 07068-1640
ITEM2. PolicyPeriod From:05-28-2017 To:05-28-2018 Term:1 Year
12:01 A.M., Standard
Time at the mailing
addressshown In ITEM 1.
Business Description:TILE CONTRACTOR
In return forthe payment ofthe premium, and subject to allthe terms of this policy, we agree with you to provide the
insurance as stated in thispolicy. This policy consists of the following coverage parts for which a premium isindicated.
Where no premium is shown, there is no coverage. This premium may be subject to adjustment.
Coverage Part(s) Premium Summary
Commercial General LiabilityCoverage Part $ NOT COVERED
Commercial Property Coverage Part $ NOT COVERED
Commercial Crime And FidelityCoverage Part $ NOT COVERED
Commercial Inland Marine Coverage Part $ NOT COVERED
Commercial Auto Coverage Part $ 471,321.00
Professional LiabilityCoverage Part $ NOT COVERED
THESE POLICY FORMS AND THE APPLICABL
NOTICE ARE EXEMPT FROM THE FILING REQUIREM
THE NEW YORK INSURANCE LAW AND REGU TIONS.
HCWEVER THE FORMS AND RATES MUST MEET THE Ai|N:MUM
ST ANDARDS OF THE NEW YORK INSURANCE LAW AND REGU .
Total Policy PremiuSLASS 1 471,321.00
$
Total Taxes, Surcharges or Fees $ 200.00
Policy Total $ 471,521. 00
Form(s) and Endorsernent(s) made a part of thispolicy at time of issue:
See Schedule of Forms and Endorsements
THIS COMMON POLICY DECLARATION AND THE SUPPLEMENTAL DECLARATION(S), TOGETHER WITH
THE COMMON POLICY CONDITIONS, COVERAGE PART(S), COVERAGE FORM(S) AND FORM(S) AND ENDORSEMENT(S), IF ANY,
COMPLETE THE ABOVE-NUMBERED POLICY.
OP-D-1 (8-10)
HomeCMceCopy
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NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
National Casualty Company
SCHEDULE OF TAXES, SURCHARGES OR FEES
Policy No. CAO7769578 Effective Date: 05-2 8-17
12:01 A.M., Standard Time
Narned Insured PORT MORRIS TILE & MARBLE, LLP AgentNo. 29718
OP-D-1 (cont.)
TAXES, SURCHARGES OR FEES BREAKDOWN :
NY-MOTOR VEHICLE LAW ENFORCEMENT FEE $ 200.00
_____________
TOTAL TAXES, SURCHARGES OR FEES $ 200 . 00
UT-126L (10-93) Homeormeecopy
(Page 8 of 66) INDEX NO. 155973/2017
FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM
NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
National Casualty Company
SCHEDULE OF FORMS AND ENDORSEMENTS
Policy No. CAO7769578 Effective Date: 05-2 8-17
12:01 A.M., Standard Time
Narned Insured PORT MORRIS TILE & MARBLE, LLP Agent No. 29718
COMMON POLICY FORMS AND ENDORSEMENTS
NOTN0583CW 10-16 NOTICE-REDOMESTICATION OF NCC TO OHIO
UT-COVPG-NY 01-16 COVER PAGE - NEW YORK
NOTX0178CW 03-16 CLAIM REPORTING INFORMATION
OP-D-1 08-10 COMMON POLICY DECLARATIONS
UT-126L 10-93 SCHEDULE OF TAXES, SURCHARGES OR FEES
UT-SP-2L 12-95 SCHEDULE OF FORMS & ENDORSRMENT
IL 00 17 11-98 COMMON POLICY CONDITIONS
IL 01 83 08-08 NEW YORK CHANGES - FRAUD
UT-74G 08-95 PUNITIVE OR EXEMPLARY DAMAGE EXCLUSION
AUTOMOBILE FORMS AND ENDORSEMENTS
CA-SD-1-NY 04-15 BUS AUTO COV FORM SUPPL DECS PAGE 1
UT-234-NY 05-05 SCHEDULE OF COVERED AUTOS YOU OWN
CA 00 01 10-13 BUSINESS AUTO COVERAGE FORM
CA 01 12 12-15 NY CHNGS BUSINESS AUTO AND MOTOR CARRIER
CA 02 25 08-14 NEW YORK CHANGES - CANCELLATION
CA 22 32 11-13 NY MANDATORY PIP ENDORSEMENT
CA 31 07 10-13 NY SUM ENDORSEMENT
CA-5 10-92 NAMED DRIVER(S) EXCL
UT-SP-2L (12-95) Homeofficecopy
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NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
IL 00 17 11 98
COMMON POLICY CONDITIONS
AllCoverage Parts included in thispolicy are subject to the following conditions.
A. Cancellation b. Give you reports on the conditions we find;
Declara- and
1. The firstNamed Insured shown in the
tions cancel this or deli- c. Recommend changes.
may policy by mailing
to us advance written notice ofcancella-
vering 2. We are not obligated to make any inspections,
tion.
surveys, reports or recommendations and any
2. We cancel this or deli- such actions we do undertake relate to in-
may policy by mailing only
vering to the firstNamed Insured written notice surabilityand the premiums to be charged. We
of cancellation at least: do not make inspections. We do not un-
safety
cancel- dertake to perform the duty of any person or
a. 10 days before the effectivedate of
pre- organization to provide for the health or safety
lation ifwe cancel for nonpayment of
of workers or the public. And we do not warrant
mium; or
thatconditions:
b. 30 days before the effectivedate of cancel-
a. Are safe or healthful; or
lation if we cancel for any other reason.
b. Comply with laws, regulations, codes or
3. We will mail or deliver our notice to the first
standards.
Named Insured's lastmailing address known to
us. 3. Paragraphs 1. and 2. ofthis condition apply not
only to us, but also to any rating,advisory, rate
4. Notice of cancellation will state the effective
service orsimilar organization which makes in-
date of cancellation. The policy period will end
surance reports or rec-
on that date. inspections, surveys,
ommendations.
5. Ifthispolicy is cancelled, we will send the first
4. Paragraph 2. ofthis condition does not apply to
Named Insured any premium refund due. If we
reports or recom-
the refund will be pro rata. If the first any inspections, surveys,
cancel, certifica-
mendations we may make relativeto
Named Insured cancels, the refund may be
under state or municipal ordin-
less than pro rata.The cancellation will be ef- tion, statutes,
ances or of pressure ves-
fective even ifwe have not made or offered a regulations, boilers,
sels or elevators.
refund.
suffi- E. Premiums
6. Ifnotice ismailed, proof of mailing willbe
cient proof of notice. The first Named Insured shown in the Declara-
tions:
B. Changes
1. Is responsible for thepayment of allpremiums;
This policy contains allthe agreements between
and
you and us concerning the insurance afforded.
The first Named Insured shown in the Declara- 2. Will be the payee for return premiums we
any
tions is authorized to make changes in the terms pay.
of this policy with our consent. This policy'sterms
F. Transfer Of Your Rights And Duties Under This
can be amended or waived only by endorsement
Policy
issued by us and made a part ofthis policy.
Your rights and duties under this policy may not
C. Examination Of Your Books And Records
be transferred without our written consent except
We examine and audit your books and in the case of death of an individual named in-
may
records as they relate to this policy at any time sured.
the period and to three years af-
during policy up If you your rights and duties willbe transferred
die,
terward.
to your legal representative but only while acting
D. Inspections And Surveys within the scope of duties as your legal represent-
ative. Until your legal representative is appointed,
1. We have the rightto:
. . anyone having proper temporary custody of your
a. Make inspections and surveys at any time; will have your rightsand duties but
property only
with respect tothat property.
IL 00 17 11 98 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1
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FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM
NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
IL 01 83 08 08
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NEW YORK CHANGES - FRAUD
This endorsement modifies insurance provided under the following:
CAPITAL ASSETS PROGRAM (OUTPUT POLICY) COVERAGE PART
COMMERCIAL AUTOMOBILE COVERAGE PART
COMMERCIAL INLAND MARINE COVERAGE PART
COMMERCIAL PROPERTY COVERAGE PART
EQUIPMENT BREAKDOWN COVERAGE PART
FARM COVERAGE PART - FARM PROPERTY - OTHER FARM PROVISIONS FORM - ADDITIONAL
COVERAGES, CONDITIONS, DEFINITIONS
FARM COVERAGE PART - LIVESTOCK COVERAGE FORM
FARM COVERAGE PART - MOBILE AGRICULTURAL MACHINERY AND EQUIPMENT COVERAGE
FORM
The CONCEALMENT, MISREPRESENTATION OR
FRAUD Condition is replaced by the following:
FRAUD
We do not provide coverage for insured ("in-
any
who has made fraudulent statements or en-
sured")
gaged in fraudulent conduct in connection with any
loss ("loss") or damage forwhich coverage is sought
under this policy.
However, with respect to insurance provided under
the COMMERCIAL AUTOMOBILE COVERAGE
"insured"
PART, we willprovide coverage to such for
damages sustained by any person who has not made
fraudulent statements or engaged in fraudulent con-
duct ifsuch damages are otherwise covered under
the policy.
IL 01 83 08 08 © Insurance Services Office, Inc.,2008 Page 1 of 1
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NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
ENDORSEMENT
National NO
Casualty Company
Attached to and forming a part of Endorsement Effective Date 05-28-17
Policy No.CAO776957 8 12:01 A.M., Standard Time
Named Insured PORT MORRIS TILE & MARBLE, LLP AgentNo. 2 9 7 18
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PUNITIVE OR EXEMPLARY DAMAGE EXCLUSION
In consideration of the premium charged, it is
agreed thatthis does not to a claim of or indem-
policy apply
nification for punitive or exemplary damages.
Punitive orexemplary damages also include any damages awarded pursuant to statute inthe form of double,
treble or other multiple damages in excess of compensatory damages.
If suit
isbrought against any insured for a claim fallingwithin coverage provided under the policy,seeking
both compensatory and punitive or exemplary damages, then the Company willafford a defense to such
action; however, the Company will have no obligation to pay for any costs, interestor damages attributable
to punitive or exemplary damages.
AUTHORIZEDREPRESENTATIVE DATE
UT-74g (8-95)
HomeOfficeCopy
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NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
National Casualty Company
COMMERCIALAUTO COVERAGE PART
BUSNESS AUTO COVERAGE FORM SUPPLEMENTAL DECLARATIONS
Policy No.. CAO7769578 Effective Date: 05-2 8-17
12:01 A.M. Standard Tirne
Named Insured: PORT MORRIS TILE & MARBLE, LLP Agent No.: 29718
Item1.-Business Description: TILE CONTRACTOR
Form of Business: 0 Corporation ¤ Limited Liabilky Company Individual O Partnership
Other:
Audit Period (ifapp!!œble): [X ] Annually Semi-Annually J Quarterly U Monthly ]
Item 2.-Schedule of Coverages and Covered Autos
This policyprovides only those comrageswhere a charge is shown in thepremiumcolumn bebw. Each ofthese coverages willapply
"autos" "autos." "Autos" "autos"
only to those shown as covered are shown as covered for a particular coverage by the entry of
one or more of the symbols from the COVERED AUTOS Section of the Business Auto Coverage Form next to the narne of the
coverage.
I Covered Limit:The Most We Will for
Coverages Pay Any Premium
Autos One Accident or Loss
Liability 7 $ 1,000,000 $ 458,367
Personal Injury Protectbn (P.I.P.) Separately stated ineach PIP endorsement,
$ 12 '2 01
(orequvabnt No-faultcoverage) minus Deductible.
Additional P.I.P. (or equivalent Separately stated in each additional P.I.P.
additional No-Fault Coverage) endorsement, minus Deductible.
Separately stated in the0.B.E.L. endorsement.
No au Coverag O E )
Aggregate No-Fault Benefits 7 $ 50, 000 INCL
|
Maximum Monthly Work Loss
Death BenefR
Other Necessary Expenses (per day) 7 $ 25
Auto Mad!ce! Payrnents
Uninsured Motorists (UM) Separately stated in each UM endorsement.
Underinsured Motorists (UlM)
Separately stated in each UIM endorsernent.
(not appuumolein NY)
$ 50 ,000 Each Accident or
Supplementary Uninsured/
7 Each Person $ 753
Underinsured MotorIsts (SUM)=
Each Accident
Physical Darnage Actual cash value, cost of repairor stated amount,
Comprehensive Coverage
whichever isless, minus any app!iceb!e Deductible
Physical Darnage Specified "auto."
for each covered (See Item 4. for hired or
Causes of Loss Coverage
borrowed "autos.")
Physical Darnage Collision Coverage
See Schedule of Covered Autos You Own.
for each disablement of a
Physical Darnage Towing and Labor . ,,
private passenger 'auto.
Rental Reimbursernent See Rental Reimbursement Endorsement
See New York Supplemental Spousal Bodily Injury
Supplemental Spousal Liability
LiabilityCoverage Endorsernent, CA 04 20.
Form(s) and endorsement(s) applying to this
Prerrium for Endorsements
coverage form and made a partof this policy at
N.Y. Motor Vehicle Enforcernent Fee SEE UT-126L
the time of issue:
Estimated Total Premium
See Sciwedüia of Forms and Endorsements- $ ,321.
, (Thispolicy rmybe subject to finalaudit.)
=The maximum amount payable under SUM coverage shallbe the policy's
SUM limits reducedand thus offset by motor vehicle
bodilyinjury insurance
liability
policyor bondpayrasataform,or on behalf
of, any negligent
partyinvolvedin the accident,
as apedfiadin the SUM endorsement.
Includescopyrightedmaterialof ISO Properties,
Inc., with its permission.
Copyright, Inc. 2013
ISO Properties,
CA-SD-1-NY (4-15) Page 1 of 5
HomeOftee Copy
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FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM
NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
National Casualty Company
COMMERCIAL AUTO COVERAGE
BUSNESS AUTO COVERAGE FORM SUPPLEMENTAL DECLARATIONS (continued)
Policy No.: _CAO7769578 Effective Date: 05-2 8-17
12:01 A.M. Standard Tirne
Named Insured: PORT MORRIS TILE & MARBLE, LLP Agent No.: 2 9718
Kem3.-Schedub of Covered Autos You Own
See Schedule of Covered Autos You Own.
Kem 4.-Schedule of Hired or Bóriswed Covered Auto Coverage and Premiums.
"Autos"
Covered Autos LiabilityCoverage-Cost of Hire Rating Basis for NOT used in your Motor Carrier Operations
(Other than Mobile Or Farm Equipment)
Fsdimated Annual Rde Per Each Estimded Annual Rde Per Each
Stde Cost of Hire $100 Cost of Hire Cost of Hire $100 Cost of Hire Premium
(Primary) (Primary) (Excess) (Excess)
Total Premium NOT APPLICABLE
"autos" "autos"
For NOT used in your motor carrier operations, cost of hire rneans the totalamount you incurfor the hireof
tutos" "employees"
you don't own (not including you borrow or rent from your partners or or their familyrnembers). Cost of
hiredoes not include charges for services perforrned by rnotor carrbrs of property or passengers.
"Autos"
Covered Autos Coverage-Cost
Liability of Hire Rating Basis for used in your Motor Carrier Operations
(Other than Mobile or Farm Equiprnent)
Fsdimated Annual Rate Per Each Estimded Annual Rde Per Each
Stge Cost of Hile $100 Cost of Hire Cost of Hire $100 Cost of Hire Premium
(Primary ) (Primary) (Excess) (Excess)
I$ I$ l$ l$ l$
Ï $ $ l $ Í $ $
l$ $ I $ l $ $
I $ $ I $ I $ $
15 $ Is 15 $
Total Premium $
"autos"
For used in your motor carrier operations, cost of hirerneans:
"trailers"
(a) The totaldollar amount of costs you incurred for the hire of automobiles (includes and semitrailers), and ifnot
included therein;
drivers'
(b) The totalremunerations of alloperators and helpers, of hired automobiles whether hired with a driver by lessor or
"employee"
an ofthe lessee,or any other third party;and
(c) The totaldollar amount of any other costs (i.e.,
repair, inaintenance, fuel,etc.)directlyassociated with operating the hired
"insured,"
autornobiles whether such costs are absorbed by the paid to the lessor or owner, or paid toothers.
Includescopyrighted inaterial
of ISO Properties,
Inc., with its permission.
Copyright, ISO Properties,
Inc. 2013
CA-SD-1-NY (4-15) Page 2 of 5
HorneOfficeCopy
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NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020
National Casualty Company
COMMERCIAL AUTO COVERAGE
BUSNESS AUTO COVERAGE FORM SUPPLEMENTAL DECLARATIONS (continued)
Policy No.: _CAO77695 7 8 Effective Date: 05 -2 8 -17
12:01 A.M. Standard Tirne
Named Insured: PORT MORRIS TILE & MARBLE, LLP Agent No.: 2 9718
Item 4.-Schedule of Hired or Borrowed Covered Auto Coverage and Premiums (continued)
"Autos"
Physical Damage Coverages-Cost of Hire Rating Basis for AII (Other than Mobile or Farm Equiprnent)
Estimded Annual Cost
Umit of Insurance of Hire For Each State
Coverage The Most We Will (Ex- Premium
Pay
Deductible cluding Autos Hired
With A Driver)
Actual cash value, cost of repairor ,
Comprehensive whichever isless, minus Deductible
for each covered "auto.".
Caus- Actual cash value, cost of repairor
Specified
es whichever isless, minus
Preview
FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 EXHIBIT A FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 Nationwide' Certification I,Ebone M Lewis, as a duly authorized National Casualty Cornpany associate entrusted with oversight of the system of record from which this copy was produced, based upon information and belief, certify under the penalty of perjury that this attached copy of CAO7769578, 05/28/2017 to 05/28/2018 was made at or near the time of certification, as part of regularly conducted business activities, and is a true and accurate copy of the official record kept as part of regular business activities. October 16. 2020 Ógnature Date EBONE M LEWIS Print Name CL Lead Processor Title (Page 2 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 ADDENDUM Some internal notes, stamps or typing on the Declaration sheet may appear. The intended use for these is internal only and may not have been a part of the policy received by the insured. Policy fees, inspection fees or taxes, or additional instructional stamps may have appeared on the policy received by the insured but may not appear on this copy. (Page 3 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 National Casualty Company NOTICE TO POLICYHOLDERS- REDOMESTICATION OF NATIONAL CASUALTY COMPANY TO OHIO On October 1, 2016, National Casualty Company moved itsdomicile from Wisconsin to Ohio. Itremains licensed to do insurance business in Wisconsin. Aside from the formal relocation of itsdomicile, there will be no change in any other relationship concerning your insurance with us. Allcompany contacts coilceriliilg claims, collection of premiums and policyholder services remain unchanged. If youhave any questions about this,please contact your agent. NOTN0583CW (10-16) (Page 4 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 Nationwide® Underwritten by: National Casualty Company Home Office:8877 Nodh Center Drive • Scottsdale, Arizona 85258 Gainey Administrative Office: 8877 North Gainey Center Drive •Scottsdale, Arizona 85258 1-800-423-7675 • A Stock Company NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. HOWEVER, THE FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEWYORKINSURANCELAWANDREGULATIONS. CLASS1 InWitness Whereof, the Company has caused this policy to be executed and attested. Secretary President The information contained herein replaces any similar information contained elsewhere in thepolicy. UT-COVPG-NY (1-16) (Page 5 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 Nationwide' Scottsdale Insurance Company National Casualty Company Scottsdale !ndemnny Company Scottsdale Surplus Lines Insurance Company CLAIM REPORTING INFORMATION Your insurance has been placed with a Nationwide® insurance company. policy Our commitment to you is to provide fast, fairclaim service. Piciliptly reporting an event that could lead to a claim, as required by your policy, helps us fulfill this commitment to you. Please refer to your policy for thisand allother terms and conditions. To report a claim, you may contact us 24 hours a day, 7 days a week, by calling 1-800-423-7675 or via our website at www.nationwideexcessandsurplus.com. Thank you foryour business and as always, we appreciate the opportunity to serve you. HOW TO REPORT A CLAIM Call 1-800-423-7675 or visit our website at www.nationwideexcessandsurplus.com. In order to expedite thisprocess, please be prepared to furnish as much of the following information as possible: • Your number policy • Date, time and location of the loss/accident • Details of the loss/accident • address and phone number of involved parties Name, any • If applicable,name of law enforcement or firedepartment with the incident number agency along Please refer to your policy for spec!!!c claim reporting myüirsrasiits. NOTX0178CW (3-16) (Page 6 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 COMMON POLICY DECI..ARATIONS . NEW National Casualty Company PolicyNumber Renewal ofNumber Home Office: CAO776957 8 Madison, Wisconsin AdministrativeOffice: 8877 NorthGainey Center Driveo Senttsde!e, Arizona 85258 1-800-423-7675 ASTOCK COMPANY ITEM 1. Named Insured and Mailing Address PORT MORRIS TILE & MARBLE, LLP 1285 OAKPOINT AVENUE BRONX NY 10474 Agent Name and Address - CRC INSURANCE SERVICES INC Agent No.: Program No.: NONE 105 EISENHOWER PKWY FL 4 29718 ROSELAND NJ 07068-1640 ITEM2. PolicyPeriod From:05-28-2017 To:05-28-2018 Term:1 Year 12:01 A.M., Standard Time at the mailing addressshown In ITEM 1. Business Description:TILE CONTRACTOR In return forthe payment ofthe premium, and subject to allthe terms of this policy, we agree with you to provide the insurance as stated in thispolicy. This policy consists of the following coverage parts for which a premium isindicated. Where no premium is shown, there is no coverage. This premium may be subject to adjustment. Coverage Part(s) Premium Summary Commercial General LiabilityCoverage Part $ NOT COVERED Commercial Property Coverage Part $ NOT COVERED Commercial Crime And FidelityCoverage Part $ NOT COVERED Commercial Inland Marine Coverage Part $ NOT COVERED Commercial Auto Coverage Part $ 471,321.00 Professional LiabilityCoverage Part $ NOT COVERED THESE POLICY FORMS AND THE APPLICABL NOTICE ARE EXEMPT FROM THE FILING REQUIREM THE NEW YORK INSURANCE LAW AND REGU TIONS. HCWEVER THE FORMS AND RATES MUST MEET THE Ai|N:MUM ST ANDARDS OF THE NEW YORK INSURANCE LAW AND REGU . Total Policy PremiuSLASS 1 471,321.00 $ Total Taxes, Surcharges or Fees $ 200.00 Policy Total $ 471,521. 00 Form(s) and Endorsernent(s) made a part of thispolicy at time of issue: See Schedule of Forms and Endorsements THIS COMMON POLICY DECLARATION AND THE SUPPLEMENTAL DECLARATION(S), TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART(S), COVERAGE FORM(S) AND FORM(S) AND ENDORSEMENT(S), IF ANY, COMPLETE THE ABOVE-NUMBERED POLICY. OP-D-1 (8-10) HomeCMceCopy (Page 7 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 National Casualty Company SCHEDULE OF TAXES, SURCHARGES OR FEES Policy No. CAO7769578 Effective Date: 05-2 8-17 12:01 A.M., Standard Time Narned Insured PORT MORRIS TILE & MARBLE, LLP AgentNo. 29718 OP-D-1 (cont.) TAXES, SURCHARGES OR FEES BREAKDOWN : NY-MOTOR VEHICLE LAW ENFORCEMENT FEE $ 200.00 _____________ TOTAL TAXES, SURCHARGES OR FEES $ 200 . 00 UT-126L (10-93) Homeormeecopy (Page 8 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 National Casualty Company SCHEDULE OF FORMS AND ENDORSEMENTS Policy No. CAO7769578 Effective Date: 05-2 8-17 12:01 A.M., Standard Time Narned Insured PORT MORRIS TILE & MARBLE, LLP Agent No. 29718 COMMON POLICY FORMS AND ENDORSEMENTS NOTN0583CW 10-16 NOTICE-REDOMESTICATION OF NCC TO OHIO UT-COVPG-NY 01-16 COVER PAGE - NEW YORK NOTX0178CW 03-16 CLAIM REPORTING INFORMATION OP-D-1 08-10 COMMON POLICY DECLARATIONS UT-126L 10-93 SCHEDULE OF TAXES, SURCHARGES OR FEES UT-SP-2L 12-95 SCHEDULE OF FORMS & ENDORSRMENT IL 00 17 11-98 COMMON POLICY CONDITIONS IL 01 83 08-08 NEW YORK CHANGES - FRAUD UT-74G 08-95 PUNITIVE OR EXEMPLARY DAMAGE EXCLUSION AUTOMOBILE FORMS AND ENDORSEMENTS CA-SD-1-NY 04-15 BUS AUTO COV FORM SUPPL DECS PAGE 1 UT-234-NY 05-05 SCHEDULE OF COVERED AUTOS YOU OWN CA 00 01 10-13 BUSINESS AUTO COVERAGE FORM CA 01 12 12-15 NY CHNGS BUSINESS AUTO AND MOTOR CARRIER CA 02 25 08-14 NEW YORK CHANGES - CANCELLATION CA 22 32 11-13 NY MANDATORY PIP ENDORSEMENT CA 31 07 10-13 NY SUM ENDORSEMENT CA-5 10-92 NAMED DRIVER(S) EXCL UT-SP-2L (12-95) Homeofficecopy (Page 9 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 IL 00 17 11 98 COMMON POLICY CONDITIONS AllCoverage Parts included in thispolicy are subject to the following conditions. A. Cancellation b. Give you reports on the conditions we find; Declara- and 1. The firstNamed Insured shown in the tions cancel this or deli- c. Recommend changes. may policy by mailing to us advance written notice ofcancella- vering 2. We are not obligated to make any inspections, tion. surveys, reports or recommendations and any 2. We cancel this or deli- such actions we do undertake relate to in- may policy by mailing only vering to the firstNamed Insured written notice surabilityand the premiums to be charged. We of cancellation at least: do not make inspections. We do not un- safety cancel- dertake to perform the duty of any person or a. 10 days before the effectivedate of pre- organization to provide for the health or safety lation ifwe cancel for nonpayment of of workers or the public. And we do not warrant mium; or thatconditions: b. 30 days before the effectivedate of cancel- a. Are safe or healthful; or lation if we cancel for any other reason. b. Comply with laws, regulations, codes or 3. We will mail or deliver our notice to the first standards. Named Insured's lastmailing address known to us. 3. Paragraphs 1. and 2. ofthis condition apply not only to us, but also to any rating,advisory, rate 4. Notice of cancellation will state the effective service orsimilar organization which makes in- date of cancellation. The policy period will end surance reports or rec- on that date. inspections, surveys, ommendations. 5. Ifthispolicy is cancelled, we will send the first 4. Paragraph 2. ofthis condition does not apply to Named Insured any premium refund due. If we reports or recom- the refund will be pro rata. If the first any inspections, surveys, cancel, certifica- mendations we may make relativeto Named Insured cancels, the refund may be under state or municipal ordin- less than pro rata.The cancellation will be ef- tion, statutes, ances or of pressure ves- fective even ifwe have not made or offered a regulations, boilers, sels or elevators. refund. suffi- E. Premiums 6. Ifnotice ismailed, proof of mailing willbe cient proof of notice. The first Named Insured shown in the Declara- tions: B. Changes 1. Is responsible for thepayment of allpremiums; This policy contains allthe agreements between and you and us concerning the insurance afforded. The first Named Insured shown in the Declara- 2. Will be the payee for return premiums we any tions is authorized to make changes in the terms pay. of this policy with our consent. This policy'sterms F. Transfer Of Your Rights And Duties Under This can be amended or waived only by endorsement Policy issued by us and made a part ofthis policy. Your rights and duties under this policy may not C. Examination Of Your Books And Records be transferred without our written consent except We examine and audit your books and in the case of death of an individual named in- may records as they relate to this policy at any time sured. the period and to three years af- during policy up If you your rights and duties willbe transferred die, terward. to your legal representative but only while acting D. Inspections And Surveys within the scope of duties as your legal represent- ative. Until your legal representative is appointed, 1. We have the rightto: . . anyone having proper temporary custody of your a. Make inspections and surveys at any time; will have your rightsand duties but property only with respect tothat property. IL 00 17 11 98 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 (Page 10 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 IL 01 83 08 08 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NEW YORK CHANGES - FRAUD This endorsement modifies insurance provided under the following: CAPITAL ASSETS PROGRAM (OUTPUT POLICY) COVERAGE PART COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART EQUIPMENT BREAKDOWN COVERAGE PART FARM COVERAGE PART - FARM PROPERTY - OTHER FARM PROVISIONS FORM - ADDITIONAL COVERAGES, CONDITIONS, DEFINITIONS FARM COVERAGE PART - LIVESTOCK COVERAGE FORM FARM COVERAGE PART - MOBILE AGRICULTURAL MACHINERY AND EQUIPMENT COVERAGE FORM The CONCEALMENT, MISREPRESENTATION OR FRAUD Condition is replaced by the following: FRAUD We do not provide coverage for insured ("in- any who has made fraudulent statements or en- sured") gaged in fraudulent conduct in connection with any loss ("loss") or damage forwhich coverage is sought under this policy. However, with respect to insurance provided under the COMMERCIAL AUTOMOBILE COVERAGE "insured" PART, we willprovide coverage to such for damages sustained by any person who has not made fraudulent statements or engaged in fraudulent con- duct ifsuch damages are otherwise covered under the policy. IL 01 83 08 08 © Insurance Services Office, Inc.,2008 Page 1 of 1 (Page 11 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 ENDORSEMENT National NO Casualty Company Attached to and forming a part of Endorsement Effective Date 05-28-17 Policy No.CAO776957 8 12:01 A.M., Standard Time Named Insured PORT MORRIS TILE & MARBLE, LLP AgentNo. 2 9 7 18 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PUNITIVE OR EXEMPLARY DAMAGE EXCLUSION In consideration of the premium charged, it is agreed thatthis does not to a claim of or indem- policy apply nification for punitive or exemplary damages. Punitive orexemplary damages also include any damages awarded pursuant to statute inthe form of double, treble or other multiple damages in excess of compensatory damages. If suit isbrought against any insured for a claim fallingwithin coverage provided under the policy,seeking both compensatory and punitive or exemplary damages, then the Company willafford a defense to such action; however, the Company will have no obligation to pay for any costs, interestor damages attributable to punitive or exemplary damages. AUTHORIZEDREPRESENTATIVE DATE UT-74g (8-95) HomeOfficeCopy (Page 12 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 National Casualty Company COMMERCIALAUTO COVERAGE PART BUSNESS AUTO COVERAGE FORM SUPPLEMENTAL DECLARATIONS Policy No.. CAO7769578 Effective Date: 05-2 8-17 12:01 A.M. Standard Tirne Named Insured: PORT MORRIS TILE & MARBLE, LLP Agent No.: 29718 Item1.-Business Description: TILE CONTRACTOR Form of Business: 0 Corporation ¤ Limited Liabilky Company Individual O Partnership Other: Audit Period (ifapp!!œble): [X ] Annually Semi-Annually J Quarterly U Monthly ] Item 2.-Schedule of Coverages and Covered Autos This policyprovides only those comrageswhere a charge is shown in thepremiumcolumn bebw. Each ofthese coverages willapply "autos" "autos." "Autos" "autos" only to those shown as covered are shown as covered for a particular coverage by the entry of one or more of the symbols from the COVERED AUTOS Section of the Business Auto Coverage Form next to the narne of the coverage. I Covered Limit:The Most We Will for Coverages Pay Any Premium Autos One Accident or Loss Liability 7 $ 1,000,000 $ 458,367 Personal Injury Protectbn (P.I.P.) Separately stated ineach PIP endorsement, $ 12 '2 01 (orequvabnt No-faultcoverage) minus Deductible. Additional P.I.P. (or equivalent Separately stated in each additional P.I.P. additional No-Fault Coverage) endorsement, minus Deductible. Separately stated in the0.B.E.L. endorsement. No au Coverag O E ) Aggregate No-Fault Benefits 7 $ 50, 000 INCL | Maximum Monthly Work Loss Death BenefR Other Necessary Expenses (per day) 7 $ 25 Auto Mad!ce! Payrnents Uninsured Motorists (UM) Separately stated in each UM endorsement. Underinsured Motorists (UlM) Separately stated in each UIM endorsernent. (not appuumolein NY) $ 50 ,000 Each Accident or Supplementary Uninsured/ 7 Each Person $ 753 Underinsured MotorIsts (SUM)= Each Accident Physical Darnage Actual cash value, cost of repairor stated amount, Comprehensive Coverage whichever isless, minus any app!iceb!e Deductible Physical Darnage Specified "auto." for each covered (See Item 4. for hired or Causes of Loss Coverage borrowed "autos.") Physical Darnage Collision Coverage See Schedule of Covered Autos You Own. for each disablement of a Physical Darnage Towing and Labor . ,, private passenger 'auto. Rental Reimbursernent See Rental Reimbursement Endorsement See New York Supplemental Spousal Bodily Injury Supplemental Spousal Liability LiabilityCoverage Endorsernent, CA 04 20. Form(s) and endorsement(s) applying to this Prerrium for Endorsements coverage form and made a partof this policy at N.Y. Motor Vehicle Enforcernent Fee SEE UT-126L the time of issue: Estimated Total Premium See Sciwedüia of Forms and Endorsements- $ ,321. , (Thispolicy rmybe subject to finalaudit.) =The maximum amount payable under SUM coverage shallbe the policy's SUM limits reducedand thus offset by motor vehicle bodilyinjury insurance liability policyor bondpayrasataform,or on behalf of, any negligent partyinvolvedin the accident, as apedfiadin the SUM endorsement. Includescopyrightedmaterialof ISO Properties, Inc., with its permission. Copyright, Inc. 2013 ISO Properties, CA-SD-1-NY (4-15) Page 1 of 5 HomeOftee Copy (Page 13 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 National Casualty Company COMMERCIAL AUTO COVERAGE BUSNESS AUTO COVERAGE FORM SUPPLEMENTAL DECLARATIONS (continued) Policy No.: _CAO7769578 Effective Date: 05-2 8-17 12:01 A.M. Standard Tirne Named Insured: PORT MORRIS TILE & MARBLE, LLP Agent No.: 2 9718 Kem3.-Schedub of Covered Autos You Own See Schedule of Covered Autos You Own. Kem 4.-Schedule of Hired or Bóriswed Covered Auto Coverage and Premiums. "Autos" Covered Autos LiabilityCoverage-Cost of Hire Rating Basis for NOT used in your Motor Carrier Operations (Other than Mobile Or Farm Equipment) Fsdimated Annual Rde Per Each Estimded Annual Rde Per Each Stde Cost of Hire $100 Cost of Hire Cost of Hire $100 Cost of Hire Premium (Primary) (Primary) (Excess) (Excess) Total Premium NOT APPLICABLE "autos" "autos" For NOT used in your motor carrier operations, cost of hire rneans the totalamount you incurfor the hireof tutos" "employees" you don't own (not including you borrow or rent from your partners or or their familyrnembers). Cost of hiredoes not include charges for services perforrned by rnotor carrbrs of property or passengers. "Autos" Covered Autos Coverage-Cost Liability of Hire Rating Basis for used in your Motor Carrier Operations (Other than Mobile or Farm Equiprnent) Fsdimated Annual Rate Per Each Estimded Annual Rde Per Each Stge Cost of Hile $100 Cost of Hire Cost of Hire $100 Cost of Hire Premium (Primary ) (Primary) (Excess) (Excess) I$ I$ l$ l$ l$ Ï $ $ l $ Í $ $ l$ $ I $ l $ $ I $ $ I $ I $ $ 15 $ Is 15 $ Total Premium $ "autos" For used in your motor carrier operations, cost of hirerneans: "trailers" (a) The totaldollar amount of costs you incurred for the hire of automobiles (includes and semitrailers), and ifnot included therein; drivers' (b) The totalremunerations of alloperators and helpers, of hired automobiles whether hired with a driver by lessor or "employee" an ofthe lessee,or any other third party;and (c) The totaldollar amount of any other costs (i.e., repair, inaintenance, fuel,etc.)directlyassociated with operating the hired "insured," autornobiles whether such costs are absorbed by the paid to the lessor or owner, or paid toothers. Includescopyrighted inaterial of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc. 2013 CA-SD-1-NY (4-15) Page 2 of 5 HorneOfficeCopy (Page 14 of 66) INDEX NO. 155973/2017 FILED: NEW YORK COUNTY CLERK 11/04/2020 05:34 PM NYSCEF DOC. NO. 103 RECEIVED NYSCEF: 11/04/2020 National Casualty Company COMMERCIAL AUTO COVERAGE BUSNESS AUTO COVERAGE FORM SUPPLEMENTAL DECLARATIONS (continued) Policy No.: _CAO77695 7 8 Effective Date: 05 -2 8 -17 12:01 A.M. Standard Tirne Named Insured: PORT MORRIS TILE & MARBLE, LLP Agent No.: 2 9718 Item 4.-Schedule of Hired or Borrowed Covered Auto Coverage and Premiums (continued) "Autos" Physical Damage Coverages-Cost of Hire Rating Basis for AII (Other than Mobile or Farm Equiprnent) Estimded Annual Cost Umit of Insurance of Hire For Each State Coverage The Most We Will (Ex- Premium Pay Deductible cluding Autos Hired With A Driver) Actual cash value, cost of repairor , Comprehensive whichever isless, minus Deductible for each covered "auto.". Caus- Actual cash value, cost of repairor Specified es whichever isless, minus