Preview
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021
NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023
EXHIBIT “D”
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021
NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
__________________________------___________________________________
JERSON GALEANO,
Plaintiff '
Index No: 160393/2021
-against-
NINHURSAG PROPERTIES LLC,
Defendant.
__________________________________________________________________Ç
NINHURSAG PROPERTIES LLC
Third-Party Index No.: 595805/2022
Third-Party Plaintiff,
-against-
SEASAM PAINTING, LLC
Third-Party Defendant.
___________________________________________________________________Ç
STATE OF NEW YORK )
COUNTY OF Dea Yos
)
David Zaga, being duly sworn, deposes and states the following based upon information
and belief:
1. I have served as a Manager of NINHURSAG PROPERTIES LLC. with regard to
38th
the property located at 325 West Street, New York, New York 10018 since January 1997.
2. I submit this Affidavit of Merit based upon personal knowledge and the records
maintained by NINHURSAG PROPERTIES LLC in its regular course of business.
2. I submit this Affidavit of Merit in support of the motion brought on behalf of the
defendant/third-party plaintiff, NINHURSAG PROPERTIES LLC, seeking an Order, pursuant to
CPLR §3215(a)(b), directing that a default judgment be entered against the third-party defendant,
SEASAM PAINTING, LLC, and scheduling an inquest at the time of trial in favor of the third-
party plaintiff, NINHURSAG PROPERTIES LLC.
3. NINHURSAG PROPERTIES LLC, retained the plaintiff's employer/third-party
38th
defendant, SEASAM PAINTING, LLC, to perform work taking place at 325 West Street,
New York, New York 10018, at the time of the plaintiff's alleged accident, as set forth in the
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021
NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023
"A."
agreement annexed hereto as Exhibit NINHURSAG PROPERTIES LLC did not perform
any work and did not supply any tools or equipment with regard to the work performed by the
plaintiff's or his employer, SEASAM PAINTING, LLC., at the time of the accident at issue
Moreover, NINHURSAG PROPERTIES LLC did not direct, supervise, manage or control the
work performed by the plaintiff or his employer, SEASAM PAINTING, LLC., at the time of the
accident at issue. Moreover, SEASAM PAINTING, LLC, was to obtain general liability
insurance on behalf of the defendant/third-party plaintiff, NINHURSAG PROPERTIES LLC, as
"A."
set forth in the document also annexed hereto as Exhibit
4. Based upon the foregoing, it is respectfully submitted that the defendant/third
party-plaintiff, NINHURSAG PROPERTIES LLC, has a meritorious case of action agaisnt
SEASAM PAINTING, LLC with regard to the allegations set forth in the Third-Party Summons
and Complaint.
Dated: May 4, 2023
New York, New York
DAVID ZA
Sworn to before me this 6 day
of /tf , 2023
LBN®oxNEWYORK
C
NOTARY PUB IC NOTg 19822
E
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021
NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023
EXHIBIT “A”
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021
NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023
Seasam Painting LLC INVOICE
1623
89-06 31st Ave
East Elmhurst, NY 11369
Office: 347-236-9145
16-¹°-
. pATE B l
CUSTOMER'S NAME: TEL:
e PBOPuerE3 LLC-.
ADDRESS:
3ze e> 5 . Tte
QUANTITY DESCRIPTION PRICE AMOUNT
ENKl:
HADJI: TAX
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021
NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023
CONTRACTORS SPECIAL POLICY DECLARATIONS PAGE
Renewal Declaration
UTICA FIRST INSURANCE COMPANY
CONSTITUTED IN OHIO AS
UTICA FIRST INSURANCE COMPANY (MUTUAL) - Insured
Direct Billed
Home Office - 5981 Airport Road, Oriskany NY 13424
Mail Address - P.O. Box 851, Utica, NY 13503-0851
Policy Number: ART 5080479 06
Renewal of Number:
NAMED INSURED AND MAILING ADDRESS Co n°ty ta e, Z p CoÓe Agent 2260000
SEASAM PAINTING LLC NORTHEAST AGENCIES INC
8906 31 AVE 8209 IBM DR BLDG 102, STE 100
EAST ELMHURST NY 11369 CHARLOTTE, NC 28262
POLICY PERIOD:12:01 A.M. Standard Time at the Location of Designated Premises.
01/21/22 01/21/23
From To
Item Prot. Rate Description and Location
Const
Number Class Group of Property Covered
1 PR 01 F Description: PAINTING-INTERIOR
Location: 8906 31 AVE
EAST ELMHURST, NY 11369
County: QUEENS
AGREEMENT
In return for your payment of the required premium, we provide the insurance described in this policy.
LIABILITY INSURANCE
COVERAGE LIMITS ANNUAL
PREMIUM
Each Occurrence Limit $ 1, 0oo, ooo /per occurrence
Medical Payment Limit $ 5, ooo /per person
General Aggregate Limit
(other than Products/Completed Work) $ 2, 000, 000
Aggregate Limit
(Products/Completed $ 2, 0oo, ooo
Work)
Fire Legal Liability $ 5o, ooo /per occurrence
Personal and Advertising Injury $ 1, ooo, ooo /per occurrence
Property Damage Deductible $ 5oo
PROPERTY INSURANCE
COVERAGE DEDUCTIBLE LIMIT AUTOMATIC REPLACEMENT ACV PROTECTIVE ANNUAL
INCREASE % COST DEVICES PREMIUM
Building
Business Personal Property
Loss of Income
Business Personal Property-
Off Premises
FORMS AND ENDORSEMENTS SEE FORMS INVENTORY PAGE
ANNUAL
FORM NUMBER DESCRIPTION PREMIUM
BAI-1 Blanket Additional Insured (Contractors)
inimum Retained Premium ANNUAL
SUB TOTAL
Name and Address
of Mortgagee: NYS Fire Fee
POLICY TOTAL
Our Authorized Representative
Countersignature Date 11/18/ 21
APDEC(01 18) AGENT COPY
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021
NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023
Artisan Policy
UTICA FIRST INSURANCE COMPANY FORMS INVENTORY PAGE
CONSTITUTED IN OHIO AS Policy Number: ART 5080479 06
UTICA FIRST INSURANCE COMPANY (MUTUAL)
Named Insured: SEASAM PAINTING LLC
Home Office - 5981 Airport Road, Oriskany NY 13424
Mail Address - P.O. Box 851, Utica, NY 13503-0851 Agent: NORTHEAST AGENCIES INC 2260000
FORMS INVENTORY
AP 0231NY (10/08) Exclusion - Water Damage PRIV0401 (04/01) Privacy Statement
AP-222 (1.00) Property Damage Liability Ded. GL890LA (1.00) Asbestos Liability Exclusion
XSP1 (12/96) Excl-Commercial Spray Painting AP-100 (1.00) Contractors Special Policy
CP-380 (12/86) New York Amendments CP-382 (10/87) N.Y. Amend (Anti-Arson End't)
GL-212 (01/87) Exclusion Explosion Collapse UFR-1 (07/11) Roofing Exclusion Endorsement
AP 0643 (12/99) Known or Damage Amend. AP 0233UF (01/08) Exclusion - War & Military Act
Injury
AP 0851UF (09/09) Other Insurance Amendment AP 0852UF (09/09) Information Distribution and
SNEXNY (1.00) Snow Removal Exclusion AP-0611 (01/99) Loss of Income 72WaitingPeriod
XCNTR (1.00) Excl of Injury to Emp,Contract AP 0853UF (01/10) Exclusion-Communicable Disease
AP 5454 (03/10) NY Amendatory Endorsement AP 0690 (06/02) EIFS Exclusion
AP 0230UF (11/05) Silica Exclusion AP 0365UF (02/07) Virus Or Bacteria Exclusion
AP 0700 (01/15) Certified Terrorism Loss CL 1045F (01/15) Notice of Terrorism Coverage
CL 0605 (01/15) Certified Terrorism Prem Discl DN 0700T (01/15) TRIPRA Discl Notice
BAI-1 (1.20) Blanket Additional Insured
Issued Date: 11/18/21
FORMINV0609 AGENT COPY
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021
NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023
AAIS AP-222
This endorsement changes the Commercial
Ed 1.0
Liability Coverages provided by this policy
- PLEASE READ THIS CAREFULLY -
PROPERTY DAMAGE LIABILITY DEDUCTIBLE
SCHEDULE
(The information required below may be shown on a separate schedule or supplemental Declarations.)
Policy Number: AR T 5 0 8 04 79 06
DEDUCTIBLE
Deductible Amount
Damage Liability········· (per
Property occurrence)
APPLICATION OF ENDORSEMENT
(Enter here any limitations on the application of this endorsement. Ifno limitation is entered, the deductibles
apply to all loss, however caused.)
The Commercial Liability Coverages section is under the Property Damage Liability Coverage, to all
amended as follows: damages because of all bodily injury or property
damage as the result of any one regard-
occurrence,
less of the number of persons or organizations who
HOW MUCH WE PAY
sustain damages because of that occurrence.
The following is added to the terms regarding "How
Much We Pay": The terms of the those with respect
policy, including
to:
Our obligation under Coverage L and N to pay
damages on behalf of the insured applies only to the 1. our rights and duties with respect to the defense of
amount of damages in excess of any deductible and
suits;
amounts stated in the schedule above as applicable to
such coverages. The limit of liability shown in this 2. the insured's duties in the event of an occurrence
policy asbeing applicable to each occurrence for
such coverages shall be reduced by the amount of irrespective of the application of the deductible
apply
such deductible. The limit of liability shown in this amount.
policy as aggregate, for such coverages shall not be
reduced by the application of such deductible We may pay any part or all of the deductible amount
amounts. to affect settlement of any claim or suit upon
and,
notification of the action taken, you shall promptly
The deductible amounts stated in the schedule apply reimburse us for such part of the deductible amount
as follows: as has been paid by us.
Per Occurrence Basis - If the deductible is on a per
occurrence basis, the deductible amount applies
AP-222 Ed 1.0 AAIS
Copyright MCMXC, American Association ofinsurance Services
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021
NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023
This
endorsement changes
AAIS
the policy
CL 0605 01 15 -- PLEASE READ THIS CAREFULLY --
Page 1 of 1
CERTIFIED TERRORISM LOSS DISCLOSURE OF
PREMIUM AND FEDERAL SHARE OF INSURED LOSSES
(The entries required to complete this endorsement will be shown
below, on the "declarations", or on the "schedule of coverages".)
Certified Terrorism LossPremium $
Additional information, if any, concerning terrorism premium:
"your" loss"
1. The portion of premium that is attributed to coverage for "certified terrorism is shown in the
Schedule above.
2. Coverage for "certified terrorism loss", to the extent that such coverage is provided by this policy or
Coverage Part, will be partially reimbursed by the United States Government, Department of Treasury under
a federal program. Under that program, the United States pays the following percentage of insured losses for
loss" "we"
"certified terrorism that exceeds the statutorily established deductible that retain:
a for insured losses occurring before January 1, 2016;
b for insured losses occurring during the 2016 calendar year;
c. for insured losses occurring during the 2017 calendar year;
d for insured losses occurring during the 2018 calendar year;
e for insured losses occurring during the 2019 calendar year; and
f. for insured losses occurring on or after January 1, 2020.
However, if aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk
Insurance as amended,
Act, exceed one hundred billion dollars in a calendar year (January 1 through
December 31), the Treasury will not make payment for any portion of the amount of such losses that
exceeds one hundred billion dollars.
loss"
If the Secretary of the Treasury determines that the aggregate amount of "certified terrorism has
exceeded one hundred billion dollars in a calendar year
"we" "our"
(January 1 through December 31), and have met insurer deductible under the Terrorism Risk
"we" loss"
Insurance Act, as amended, will not pay for any portion of "certified terrorism that exceeds one
loss"
hundred billion dollars. If the "certified terrorism exceeds one hundred billion dollars in a calendar year
(January 1 through December 31), losses up to one hundred billion dollars are subject to pro rata allocation
in accordance with procedures established by the Secretary of the Treasury under the Terrorism Risk
Insurance Act, as amended.
CL 0605 01 15
Copyright, American Association of Insurance Services, Inc., 2015
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021
NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023
AAIS
CL 1045F 01 15
Page 1 of 2
Insurance Company: Utica First Insurance Company
Policy Number: ART 5080479 06
Named Insured: SEASAM PAINTING LLC
POLICYHOLDER DISCLOSURE
NOTICE OF TERRORISM INSURANCE COVERAGE
You are hereby notified that under the Terrorism Risk
Insurance Act, as amended, you have a right to purchase
insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act. See the next
page for a further description of an act of terrorism as provided under the Act.
ACCEPTANCE OR REJECTION OF TERRORISM INSURANCE COVERAGE
You may accept or reject this offer of coverage. If you choose to accept
this coverage, the premium for this
coverage is payable according to the terms of your
billing notice. You may reject this offer by completing and
signing the enclosed statement and returning it to us. If you send us a signed rejection of coverage, your policy
will exclude coverage for certified terrorism losses.
Insurers should include the following in a Notice prepared for policies that are subject to Standard Fire
Policy statutes with respect to losses resulting from terrorism:
NY
In the state of , a terrorism exclusion makes an exception for fire losses resulting from an act of terrorism.
Accordingly, if you
reject the offer of terrorism coverage as provided under the program, that rejection is not
applicable to fire losses resulting from an act of terrorism. In this state, the coverage in your policy for such fire
losses will continue. The premium for such fire coverage is stated below. This premium is due whether or not you
reject the offer described above for terrorism coverage.
One of the following premiums is due:
If you accept this offer, the premium for terrorism coverage is $
If you reject this offer, the premium for terrorism (fire only) coverage is
I accept this offer of terrorism coverage and acknowledge that I have been notified that under the
Terrorism Risk Insurance Act, as amended, any losses resulting from certified acts of terrorism under
my policy may be partially reimbursed by the United States government and may be subject to a
$100 billion cap that may reduce my coverage, and I have been notified of the portion of my premium
attributable to such coverage.
I hereby reject this offer of terrorism coverage. I understand that an exclusion of certified terrorism
losses will be made part of this policy. I also acknowledge that I have been notified that under the
Terrorism Risk Insurance Act, as amended, any fire losses resulting from certified acts of terrorism
under my policy may be partially reimbursed by the United States government and may be subject to
a $100 billion cap that may reduce my coverage, and I have been notified of the portion of my
premium attributable to such coverage.
Copyright, American Association of Insurance Services, Inc., 2015
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021
NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023
AAIS
CL 1045F 01 15
Page 2 of 2
You should know
that where coverage is provided by this policy for losses resulting from certified acts of terrorism,
such losses
may be partially reimbursed by the United States government under a formula established by federal
law. However, your policy may contain other exclusions which might affect your coverage, such as an exclusion for
nuclear events. Under the formula, the United States government generally reimburses 85% through 2015; 84%
beginning on January 1, 2016; 83% beginning on January 1, 2017; 82% beginning on January 1, 2018; 81%
beginning on January
1, 2019; and 80% beginning on January 1, 2020 of covered terrorism losses exceeding the
statutorily established deductible paid by the insurance company providing the coverage. The premium charged for
this coverage is shown above and does not include any charges for the portion of loss that may be covered by the
federal government under the Act.
You should also know that the Terrorism
Risk Insurance Act, as amended, contains a $100 billion cap that limits
insurers'
U.S. government reimbursement as well as
liability for losses resulting from certified acts of terrorism
when the amount of such losses in any one calendar year exceeds $100 billion. If the aggregate insured losses for
all insurers exceed $100 billion, your coverage may be reduced.
Policyholder's Signature: Date:
Print Name
The following excerpt from the Act is provided for your information:
terrorism"
According to Section 102(1) of the Terrorism Risk Insurance Act, as amended, "The term "act of means
any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security,
and the Attorney General of the United States ---- (i) to be an act of terrorism; (ii) to be a violent act or an act that
is dangerous to (I) human life; (II) property; or (III) infrastructure; (iii) to have resulted in damage within the United
States, or outside the United States in the case of (I) an air carrier or vessel described in paragraph (5)(B); or (II)
the premises of a United States mission; and (iv) to have been committed by an individual or individuals, as part of
an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the
coercion."
United States Government by
CL 1045F 01 15
Copyright, American Association of Insurance Services, Inc., 2015
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021
NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023
AAIS GL-212
This endorsement changes the Commercial
(Ed. 1-87)
Liability Coverages provided by this policy
- PLEASE READ THIS CAREFULLY -
EXCLUSION-
EXPLOSION, COLLAPSE,
UNDERGROUND PROPERTY DAMAGE HAZARD
(The information required below may be shown on a separate schedule or supplemental Declarations.)
SCHEDULE Excluded Hazard(s)
Policy Number : ART 5 0 8 04 79 06 ® Explosion Hazard
Page"
Location: "See Declarations ® Collapse Hazard
Description: PAINTING - INTERIOR ® Underground Property
Damage Hazard
The Commercial Liability Coverage of this policy is amended as follows:
Underground Damage -
Preview
FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021 NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023 EXHIBIT “D” FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021 NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK __________________________------___________________________________ JERSON GALEANO, Plaintiff ' Index No: 160393/2021 -against- NINHURSAG PROPERTIES LLC, Defendant. __________________________________________________________________Ç NINHURSAG PROPERTIES LLC Third-Party Index No.: 595805/2022 Third-Party Plaintiff, -against- SEASAM PAINTING, LLC Third-Party Defendant. ___________________________________________________________________Ç STATE OF NEW YORK ) COUNTY OF Dea Yos ) David Zaga, being duly sworn, deposes and states the following based upon information and belief: 1. I have served as a Manager of NINHURSAG PROPERTIES LLC. with regard to 38th the property located at 325 West Street, New York, New York 10018 since January 1997. 2. I submit this Affidavit of Merit based upon personal knowledge and the records maintained by NINHURSAG PROPERTIES LLC in its regular course of business. 2. I submit this Affidavit of Merit in support of the motion brought on behalf of the defendant/third-party plaintiff, NINHURSAG PROPERTIES LLC, seeking an Order, pursuant to CPLR §3215(a)(b), directing that a default judgment be entered against the third-party defendant, SEASAM PAINTING, LLC, and scheduling an inquest at the time of trial in favor of the third- party plaintiff, NINHURSAG PROPERTIES LLC. 3. NINHURSAG PROPERTIES LLC, retained the plaintiff's employer/third-party 38th defendant, SEASAM PAINTING, LLC, to perform work taking place at 325 West Street, New York, New York 10018, at the time of the plaintiff's alleged accident, as set forth in the FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021 NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023 "A." agreement annexed hereto as Exhibit NINHURSAG PROPERTIES LLC did not perform any work and did not supply any tools or equipment with regard to the work performed by the plaintiff's or his employer, SEASAM PAINTING, LLC., at the time of the accident at issue Moreover, NINHURSAG PROPERTIES LLC did not direct, supervise, manage or control the work performed by the plaintiff or his employer, SEASAM PAINTING, LLC., at the time of the accident at issue. Moreover, SEASAM PAINTING, LLC, was to obtain general liability insurance on behalf of the defendant/third-party plaintiff, NINHURSAG PROPERTIES LLC, as "A." set forth in the document also annexed hereto as Exhibit 4. Based upon the foregoing, it is respectfully submitted that the defendant/third party-plaintiff, NINHURSAG PROPERTIES LLC, has a meritorious case of action agaisnt SEASAM PAINTING, LLC with regard to the allegations set forth in the Third-Party Summons and Complaint. Dated: May 4, 2023 New York, New York DAVID ZA Sworn to before me this 6 day of /tf , 2023 LBN®oxNEWYORK C NOTARY PUB IC NOTg 19822 E FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021 NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023 EXHIBIT “A” FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021 NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023 Seasam Painting LLC INVOICE 1623 89-06 31st Ave East Elmhurst, NY 11369 Office: 347-236-9145 16-¹°- . pATE B l CUSTOMER'S NAME: TEL: e PBOPuerE3 LLC-. ADDRESS: 3ze e> 5 . Tte QUANTITY DESCRIPTION PRICE AMOUNT ENKl: HADJI: TAX FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021 NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023 CONTRACTORS SPECIAL POLICY DECLARATIONS PAGE Renewal Declaration UTICA FIRST INSURANCE COMPANY CONSTITUTED IN OHIO AS UTICA FIRST INSURANCE COMPANY (MUTUAL) - Insured Direct Billed Home Office - 5981 Airport Road, Oriskany NY 13424 Mail Address - P.O. Box 851, Utica, NY 13503-0851 Policy Number: ART 5080479 06 Renewal of Number: NAMED INSURED AND MAILING ADDRESS Co n°ty ta e, Z p CoÓe Agent 2260000 SEASAM PAINTING LLC NORTHEAST AGENCIES INC 8906 31 AVE 8209 IBM DR BLDG 102, STE 100 EAST ELMHURST NY 11369 CHARLOTTE, NC 28262 POLICY PERIOD:12:01 A.M. Standard Time at the Location of Designated Premises. 01/21/22 01/21/23 From To Item Prot. Rate Description and Location Const Number Class Group of Property Covered 1 PR 01 F Description: PAINTING-INTERIOR Location: 8906 31 AVE EAST ELMHURST, NY 11369 County: QUEENS AGREEMENT In return for your payment of the required premium, we provide the insurance described in this policy. LIABILITY INSURANCE COVERAGE LIMITS ANNUAL PREMIUM Each Occurrence Limit $ 1, 0oo, ooo /per occurrence Medical Payment Limit $ 5, ooo /per person General Aggregate Limit (other than Products/Completed Work) $ 2, 000, 000 Aggregate Limit (Products/Completed $ 2, 0oo, ooo Work) Fire Legal Liability $ 5o, ooo /per occurrence Personal and Advertising Injury $ 1, ooo, ooo /per occurrence Property Damage Deductible $ 5oo PROPERTY INSURANCE COVERAGE DEDUCTIBLE LIMIT AUTOMATIC REPLACEMENT ACV PROTECTIVE ANNUAL INCREASE % COST DEVICES PREMIUM Building Business Personal Property Loss of Income Business Personal Property- Off Premises FORMS AND ENDORSEMENTS SEE FORMS INVENTORY PAGE ANNUAL FORM NUMBER DESCRIPTION PREMIUM BAI-1 Blanket Additional Insured (Contractors) inimum Retained Premium ANNUAL SUB TOTAL Name and Address of Mortgagee: NYS Fire Fee POLICY TOTAL Our Authorized Representative Countersignature Date 11/18/ 21 APDEC(01 18) AGENT COPY FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021 NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023 Artisan Policy UTICA FIRST INSURANCE COMPANY FORMS INVENTORY PAGE CONSTITUTED IN OHIO AS Policy Number: ART 5080479 06 UTICA FIRST INSURANCE COMPANY (MUTUAL) Named Insured: SEASAM PAINTING LLC Home Office - 5981 Airport Road, Oriskany NY 13424 Mail Address - P.O. Box 851, Utica, NY 13503-0851 Agent: NORTHEAST AGENCIES INC 2260000 FORMS INVENTORY AP 0231NY (10/08) Exclusion - Water Damage PRIV0401 (04/01) Privacy Statement AP-222 (1.00) Property Damage Liability Ded. GL890LA (1.00) Asbestos Liability Exclusion XSP1 (12/96) Excl-Commercial Spray Painting AP-100 (1.00) Contractors Special Policy CP-380 (12/86) New York Amendments CP-382 (10/87) N.Y. Amend (Anti-Arson End't) GL-212 (01/87) Exclusion Explosion Collapse UFR-1 (07/11) Roofing Exclusion Endorsement AP 0643 (12/99) Known or Damage Amend. AP 0233UF (01/08) Exclusion - War & Military Act Injury AP 0851UF (09/09) Other Insurance Amendment AP 0852UF (09/09) Information Distribution and SNEXNY (1.00) Snow Removal Exclusion AP-0611 (01/99) Loss of Income 72WaitingPeriod XCNTR (1.00) Excl of Injury to Emp,Contract AP 0853UF (01/10) Exclusion-Communicable Disease AP 5454 (03/10) NY Amendatory Endorsement AP 0690 (06/02) EIFS Exclusion AP 0230UF (11/05) Silica Exclusion AP 0365UF (02/07) Virus Or Bacteria Exclusion AP 0700 (01/15) Certified Terrorism Loss CL 1045F (01/15) Notice of Terrorism Coverage CL 0605 (01/15) Certified Terrorism Prem Discl DN 0700T (01/15) TRIPRA Discl Notice BAI-1 (1.20) Blanket Additional Insured Issued Date: 11/18/21 FORMINV0609 AGENT COPY FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021 NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023 AAIS AP-222 This endorsement changes the Commercial Ed 1.0 Liability Coverages provided by this policy - PLEASE READ THIS CAREFULLY - PROPERTY DAMAGE LIABILITY DEDUCTIBLE SCHEDULE (The information required below may be shown on a separate schedule or supplemental Declarations.) Policy Number: AR T 5 0 8 04 79 06 DEDUCTIBLE Deductible Amount Damage Liability········· (per Property occurrence) APPLICATION OF ENDORSEMENT (Enter here any limitations on the application of this endorsement. Ifno limitation is entered, the deductibles apply to all loss, however caused.) The Commercial Liability Coverages section is under the Property Damage Liability Coverage, to all amended as follows: damages because of all bodily injury or property damage as the result of any one regard- occurrence, less of the number of persons or organizations who HOW MUCH WE PAY sustain damages because of that occurrence. The following is added to the terms regarding "How Much We Pay": The terms of the those with respect policy, including to: Our obligation under Coverage L and N to pay damages on behalf of the insured applies only to the 1. our rights and duties with respect to the defense of amount of damages in excess of any deductible and suits; amounts stated in the schedule above as applicable to such coverages. The limit of liability shown in this 2. the insured's duties in the event of an occurrence policy asbeing applicable to each occurrence for such coverages shall be reduced by the amount of irrespective of the application of the deductible apply such deductible. The limit of liability shown in this amount. policy as aggregate, for such coverages shall not be reduced by the application of such deductible We may pay any part or all of the deductible amount amounts. to affect settlement of any claim or suit upon and, notification of the action taken, you shall promptly The deductible amounts stated in the schedule apply reimburse us for such part of the deductible amount as follows: as has been paid by us. Per Occurrence Basis - If the deductible is on a per occurrence basis, the deductible amount applies AP-222 Ed 1.0 AAIS Copyright MCMXC, American Association ofinsurance Services FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021 NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023 This endorsement changes AAIS the policy CL 0605 01 15 -- PLEASE READ THIS CAREFULLY -- Page 1 of 1 CERTIFIED TERRORISM LOSS DISCLOSURE OF PREMIUM AND FEDERAL SHARE OF INSURED LOSSES (The entries required to complete this endorsement will be shown below, on the "declarations", or on the "schedule of coverages".) Certified Terrorism LossPremium $ Additional information, if any, concerning terrorism premium: "your" loss" 1. The portion of premium that is attributed to coverage for "certified terrorism is shown in the Schedule above. 2. Coverage for "certified terrorism loss", to the extent that such coverage is provided by this policy or Coverage Part, will be partially reimbursed by the United States Government, Department of Treasury under a federal program. Under that program, the United States pays the following percentage of insured losses for loss" "we" "certified terrorism that exceeds the statutorily established deductible that retain: a for insured losses occurring before January 1, 2016; b for insured losses occurring during the 2016 calendar year; c. for insured losses occurring during the 2017 calendar year; d for insured losses occurring during the 2018 calendar year; e for insured losses occurring during the 2019 calendar year; and f. for insured losses occurring on or after January 1, 2020. However, if aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance as amended, Act, exceed one hundred billion dollars in a calendar year (January 1 through December 31), the Treasury will not make payment for any portion of the amount of such losses that exceeds one hundred billion dollars. loss" If the Secretary of the Treasury determines that the aggregate amount of "certified terrorism has exceeded one hundred billion dollars in a calendar year "we" "our" (January 1 through December 31), and have met insurer deductible under the Terrorism Risk "we" loss" Insurance Act, as amended, will not pay for any portion of "certified terrorism that exceeds one loss" hundred billion dollars. If the "certified terrorism exceeds one hundred billion dollars in a calendar year (January 1 through December 31), losses up to one hundred billion dollars are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury under the Terrorism Risk Insurance Act, as amended. CL 0605 01 15 Copyright, American Association of Insurance Services, Inc., 2015 FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021 NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023 AAIS CL 1045F 01 15 Page 1 of 2 Insurance Company: Utica First Insurance Company Policy Number: ART 5080479 06 Named Insured: SEASAM PAINTING LLC POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE You are hereby notified that under the Terrorism Risk Insurance Act, as amended, you have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act. See the next page for a further description of an act of terrorism as provided under the Act. ACCEPTANCE OR REJECTION OF TERRORISM INSURANCE COVERAGE You may accept or reject this offer of coverage. If you choose to accept this coverage, the premium for this coverage is payable according to the terms of your billing notice. You may reject this offer by completing and signing the enclosed statement and returning it to us. If you send us a signed rejection of coverage, your policy will exclude coverage for certified terrorism losses. Insurers should include the following in a Notice prepared for policies that are subject to Standard Fire Policy statutes with respect to losses resulting from terrorism: NY In the state of , a terrorism exclusion makes an exception for fire losses resulting from an act of terrorism. Accordingly, if you reject the offer of terrorism coverage as provided under the program, that rejection is not applicable to fire losses resulting from an act of terrorism. In this state, the coverage in your policy for such fire losses will continue. The premium for such fire coverage is stated below. This premium is due whether or not you reject the offer described above for terrorism coverage. One of the following premiums is due: If you accept this offer, the premium for terrorism coverage is $ If you reject this offer, the premium for terrorism (fire only) coverage is I accept this offer of terrorism coverage and acknowledge that I have been notified that under the Terrorism Risk Insurance Act, as amended, any losses resulting from certified acts of terrorism under my policy may be partially reimbursed by the United States government and may be subject to a $100 billion cap that may reduce my coverage, and I have been notified of the portion of my premium attributable to such coverage. I hereby reject this offer of terrorism coverage. I understand that an exclusion of certified terrorism losses will be made part of this policy. I also acknowledge that I have been notified that under the Terrorism Risk Insurance Act, as amended, any fire losses resulting from certified acts of terrorism under my policy may be partially reimbursed by the United States government and may be subject to a $100 billion cap that may reduce my coverage, and I have been notified of the portion of my premium attributable to such coverage. Copyright, American Association of Insurance Services, Inc., 2015 FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021 NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023 AAIS CL 1045F 01 15 Page 2 of 2 You should know that where coverage is provided by this policy for losses resulting from certified acts of terrorism, such losses may be partially reimbursed by the United States government under a formula established by federal law. However, your policy may contain other exclusions which might affect your coverage, such as an exclusion for nuclear events. Under the formula, the United States government generally reimburses 85% through 2015; 84% beginning on January 1, 2016; 83% beginning on January 1, 2017; 82% beginning on January 1, 2018; 81% beginning on January 1, 2019; and 80% beginning on January 1, 2020 of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The premium charged for this coverage is shown above and does not include any charges for the portion of loss that may be covered by the federal government under the Act. You should also know that the Terrorism Risk Insurance Act, as amended, contains a $100 billion cap that limits insurers' U.S. government reimbursement as well as liability for losses resulting from certified acts of terrorism when the amount of such losses in any one calendar year exceeds $100 billion. If the aggregate insured losses for all insurers exceed $100 billion, your coverage may be reduced. Policyholder's Signature: Date: Print Name The following excerpt from the Act is provided for your information: terrorism" According to Section 102(1) of the Terrorism Risk Insurance Act, as amended, "The term "act of means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States ---- (i) to be an act of terrorism; (ii) to be a violent act or an act that is dangerous to (I) human life; (II) property; or (III) infrastructure; (iii) to have resulted in damage within the United States, or outside the United States in the case of (I) an air carrier or vessel described in paragraph (5)(B); or (II) the premises of a United States mission; and (iv) to have been committed by an individual or individuals, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the coercion." United States Government by CL 1045F 01 15 Copyright, American Association of Insurance Services, Inc., 2015 FILED: NEW YORK COUNTY CLERK 07/28/2023 11:19 AM INDEX NO. 160393/2021 NYSCEF DOC. NO. 28 RECEIVED NYSCEF: 07/28/2023 AAIS GL-212 This endorsement changes the Commercial (Ed. 1-87) Liability Coverages provided by this policy - PLEASE READ THIS CAREFULLY - EXCLUSION- EXPLOSION, COLLAPSE, UNDERGROUND PROPERTY DAMAGE HAZARD (The information required below may be shown on a separate schedule or supplemental Declarations.) SCHEDULE Excluded Hazard(s) Policy Number : ART 5 0 8 04 79 06 ® Explosion Hazard Page" Location: "See Declarations ® Collapse Hazard Description: PAINTING - INTERIOR ® Underground Property Damage Hazard The Commercial Liability Coverage of this policy is amended as follows: Underground Damage -