ecc board of trustees documents/2014_08_28...ecc board of trustees executive summary date: august...
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ECC Board of Trustees
Executive Summary
Date: August 28, 2014
Subcommittee: Academic Affairs
Agenda Item: Affiliation Agreement recommended by ECC Health Sciences Division with Elderwood This item is for: For Board's Approval Backup Documentation: Attached to this document Background Information:
In order to provide students with needed competencies and standards of proficiency required for degree completion, the Associate Vice President of the Health Sciences Division recommends a clinical Affiliation Agreement between ECC and Elderwood facilities at seven sites (Amherst, Cheektowaga, Grand Island, Hamburg, Lancaster, Wheatfield and Williamsville).
Reasons for Recommendation:
To provide students access to required clinical, technical and educational experience and training directly related to the successful completion of curricula.
Fiscal Implications:
Required courses for student graduation.
Consequences of Negative Action:
Students would not have access to required clinical learning experiences.
Steps Following Approval:
Review and approval by the Executive Vice President of Legal Affairs.
Contact Information If Any Questions:
Richard C. Washousky, Executive Vice President of Academic Affairs, North Campus Phone: (716) 851-1500 / E-Mail: [email protected]
Patrick J. Wiles, Associate Vice President of Health Sciences, North Campus Phone: (716) 851-1901 / Email: [email protected]
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Erie Community College Affiliation Agreement
This agreement is made as of this __ day of June, 2014, by and between ERIE
COMMUNITY COLLEGE, an educational institution part of a municipal corporation of the State of
New York, namely, the County of Erie [hereinafter referred to as "ECC"], and ELDERWOOD, an
individual, partnership, limited liability company, corporation or other organization doing business in
the State ofNew York [hereinafter referred to as the "HOST'']. with individual facilities located at:
Efderwood at Amherst, 4459 Bailey Avenue, Amherst, NY 14226
Elderwood at Cheektowaga, 225 Bennett Road, Cheektowaga, NY 14227
Elderwood at Grand Island, 2850 Grand Island Boulevard, Grand Island, NY 14072
Elderwood at Hamburg, 5775 Maelou Drive, Hamburg, NY 14075
Elderwood at Lancaster, 1818 Como Park Boulevard, Lancaster, NY 14086
Elderwood at Wheatfield, 2600 Niagara Falls Boulevard, Wheatfield, NY 14304
Elderwood at Williamsville, 200 Bassett Road, Williamsville, NY 14221
WITNESSETH
WHEREAS, ECC and the HOST are desirous of developing a program pursuant to which
ECC students may make use of some or all of the HOST's facilities for the purpose of enabling said
students to gain field clinical, technical and educational experience and training directly related to
and/or required for successful completion of the ECC courses or programs in which the students are
enrolled, and
WHEREAS, the HOST is willing to affordassigned ECC students access to the HOST's
facilities for such purpose, upon the terms and conditions set forth herein, and to accept said students
without regard to sex, race, color, disability, national and ethnic origin, age, sexual orientation,
religion or creed.
2993161_3
Page 1 of 8
.~
,,, ... ,,_,_,_, _____ _ the assigned ECC students and the ECC faculty/instructors designated in the Appendix (ces), as
availability permits.
6. The HOST will make known to the designated ECC Preceptor all rules, regulations
and procedures of the HOST to be applicable to the assigned ECC students and ECC will be
responsible for ensuring that the assigned ECC students are informed as to such policies and oftheir
need to comply with same. Assigned students shall be required to sign HOST's "Student
Acknowledgement Form," a copy of which is attached hereto as Attachment A, before being allowed
to participate in this program. Signed Student Acknowledgment Forms must be submitted to HOST.
7. The HOST will have the right to remove any assigned ECC student or designated
ECC faculty/instructor who fails to comply with the HOST's rules, regulations and procedures or
whose condition or conduct jeopardizes the well-being or safety of any patient, resident or employee
of the HOST or any other person.
8. ECC will instruct the assigned students as to their ethical and legal obligations relative
to confidentiality and to respect and preserve the presumptively confidential nature of all information
which the students may obtain while gaining field clinical, technical and educational experience and
training at the HOST's facilities, whether obtained from patients/significant others, another student,
any staff or records of the HOST or otherwise. ECC shall be responsible for providing students with
an overview and understanding of the Health Insurance Portability and Accountability Act of 1996, as
amended (HIP AA).
9. ECC shall ensure that students keep all confidential information obtained during the
program confidential and comply with all policies, procedures and regulations of the HOST (including
HOST's prohibition against taking, storing or transmitting any photographic, video or other images via
cell phone, laptop, tablet, camera, Google Glass, or any other medium or device while on HOST's
premises), as well as all local, state and federal laws, including but not limited to the provisions of
HIPAA.
10. ECC's designated faculty/instructors and assigned students shall not be deemed
employees of the HOST nor shall any monetary consideration be paid by or to the HOST relative to
the field clinical, technical and educational experience and training provided under this Agreement.
2993161_3 Page 3 of 8
11. ECC will neither publish nor cause to be published any material related to the field
clinical, technical and educational experience and training provided under this Agreement without
prior written approval of the HOST.
12. The HOST will have the right to limit the number ofECC students who may be
assigned to participate in the field clinical, technical and educational experience and training to be
provided under this Agreement.
13. Except as otherwise specifically provided herein, including Appendix(ces), neither
ECC nor the HOST shall be financially responsible for expenses incurred by the assigned ECC
students, including, but not limited to, all housing, meals, parking and transportation to and from ECC
and/or the HOST's facilities.
14. Each student, at his or her own expense, will have an annual health examination,
screening and immunizations consistent with New York State Department of Health requirements,
including a physical examination of sufficient scope so as to ensure that the said students do not
assume their duties at the HOST's faciiities unless free from any health impairment which poses a
risk to patients or otherwise interferes with the performance of said duties.
15. The HOST will assist ECC students and any designated ECC faculty/instructor with
obtaining emergency medical care who may become ill or incapacitated or who may be injured while
at the HOST's facilities, at the expense of such student or faculty/instructor.
16. ECC, through the county ofErie, is largely self-insured with regard to automobile
liability, general liability, medical malpractice liability and workers' compensation matters. In the
event that the HOST receives notice of any claim arising out of or related to the field clinical,
technical and educational experience and training provided under this Agreement, the HOST will
immediately give notice thereof to ECC, through its designated faculty/instructor.
17. Each party shall purchase, maintain, and show existing proof of, professional liability
insurance in the minimum amounts of$1,000,000.00 each claim/$3,000,000.00 aggregate per policy 2993161_3
Page 4 of 8
"""'"" "'" '""'""'' _________________ _
year and general liability insurance with minimum limits of$1,000,000.00 each person/$3,000,000.00
each occurrence combined bodily injury and property damage covering the insured said Party and the
activities of its faculty, employees, officers and agents. Said insurance shall be occurrence based
liability insurance (or the equivalent combination of claims made-based insurance with appropriate
"tail" coverage). Each party shall provide the other annually with suitable insurance certificates to
indicate such coverage and also to include a thirty (30)-day notice to the other of an event of
cancellation, non-renewal or material change with respect to each policy. A copy of each party's
policy shall be made available to the other upon request.
18. ECC, to include the County of Erie, agrees to defend, indemnifY and hold harmless the
HOST and its agents and employees from and against all claims, damages, lqsses and causes of action
arising out of or resulting from actions or omissions, materials provided, services rendered or other
performance of or by ECC, its agents, employees, students, faculty/instructors or volunteers, pursuant
to this Agreement.
19. With regard to any field clinical, technical and educational experience and training
involving the provision by assigned ECC students of healthcare services to patients:
A. The HOST will maintain ultimate and sole responsibility for all supervision of all
such patient or resident care, including any required medical direction, oversight and control related to
such care.
B. A professional staff member of the HOST may intervene in such patient and
resident care at any time and any manner deemed necessary, as dictated by the circumstances, so as to
safeguard patient(s) and resident(s), including without limitation the issuance of emergency medical
direction to the ECC student( s) or the resumption by the HOST of the provision of such care to
patient(s) or resident(s).
C. ECC students will be instructed by ECC to immediately request guidance and
direction from either a professional staff member of the HOST or an ECC faculty/instructor where
the student becomes unsure as to how to proceed with the care of a patient or where a patient's
condition appears to the student to require the immediate attention of a professional staff member of
the HOST.
2993161_3 Page 5 of 8
D. The designated ECC faculty/instructors will provide orientation to the HOST's
professional staff relative to the courses or programs in which the assigned ECC students are enrolled
and the students previous field clinical, technical and educational experience and training.
E. HOST shall provide students with an orientation program, including a review of the
rules, policies and procedures of HOST.
20. ECC and the HOST each agree to comply with all applicable laws, rules, and
regulations with respect to the performance of this Agreement.
21. Except as may otherwise be set forth in the Appendix(ces), and unless sooner
terminated in accordance with this Agreement Agreement will commence as of the date first written
above, will continue in full force and effect for a period of one (1) year and will thereafter
automatically renew for additional one (1) year terms unless terminated in accordance with this
Agreement.
22. This Agreement may be terminated by either party for any reason upon ninety (90)
days prior wTitten notice addressed to the other at the address set forth in the Appendix(ces), provided,
however, that no such termination on the part of the HOST shall take effect prior to the conclusion of
the student training rotation during which such notice of termination is given, unless patient or
resident safety is at issue, to be determined in HOST's sole discretion, in which case such termination
shall take effect immediately.
23. This Agreement may be modified only upon the further mutual consent of ECC and
the HOST and then only by means of ariother writing, approved and executed in a similar fashion to
the approval and execution of this Agreement.
24. This Agreement shall be governed by and construed in accordance with the laws of the
State of New York. The illegality or non-enforceability of any provision of this Agreement shall not
affect the validity of remaining provisions.
2993161_3 Page 6 of 8
25. This Agreement, including any Appendix (ces), supersedes all prior understandings
and agreements between the parties, both written and oral.
26. Several copies ofthis Agreement may be executed by the parties, each of which shall
be deemed an original for all purposes, and all of which together shall constitute one and the same
instrument.
27. Whenever, under the terms of this Agreement, notice is required or permitted to be
given by any party or to any other party, such notice shall be deemed to have been sufficiently given if
written, when deposited in the United States Mail, in a properly stamped envelope, certified or
registered mail, return receipt requested, addressed to the party to whom it is to be given at the address
hereinafter set forth. Either party may change its respective address by written notice in accordance
with this paragraph.
To FACILITY/AGENCY: With a copy (which shall not constitute notice) to:
Elderwood Administrative Services Post Acute Partners
Attn: Randy Muenzner
7 Limestone Drive
Williamsville, NY 14221
Ifto COLLEGE:
Erie Community College
Attn:
4041 Southwestern Blvd.
Orchard Park, NY 14127
Attn: General Counsel
641 Lexington A venue
New York, New York 10022
With a copy (which shall not constitute notice) to:
Erie Community College
Attn: Kristin Klein-Wheaton
4041 Southwestern Blvd.
Orchard Park, NY 14127
28. This Agreement may not be assigned in whole or in part without the prior written
consent of the parties.
ERIE COMMUNITY COLLEGE
By: Jack Quinn ECC President
Date: ---------------------
2993161_3 Page 7 of 8
2 ELDEl,tW OD ~
{j ~~4;1tl~~-/ By: Randy Muenzilf!'
Vice I):"esiden) of Operations Date: {P /i-f/ Ulf¥
'
STATE OF NEW YORK COUNTY OF ERIE
l" 1 'f '1l ~d ~ $J Jterr"-ntr On the 1./ In day of :Jv'lt. , before me personally came enm, to me known to be the individual described in, and who, executed, the foregoing instrument and acknowledge that he executed the same.
?~r~&:_,_ Notary Public
APPROVED AS TO FORM:
By: Kristin Klein-Wheaton
Executive Vice President, Legal Affairs
Date nn,.. :l:l L-'....,'-"• 11 ----------
STATE OF NEW YORK
COUNTY OF ERIE
PATRICIA K. SHEA Notary Public of NY State Qualified in Erie County My Comrnission Expires
June 30, IJLZ tJ 1 'il
On the ___ day of _____ , 2014, before me personally came Jack Quinn, to me known to be the
individual described in, and who, executed the foregoing instrument and acknowledge that he executed the same.
Notary Public
2993161_3
Page 8 of 8
·-··""""'"""""' __________________ _ ~RD• CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDDIYYYY)
06/04/2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(Jes) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement( a).
PRODUCER 1-617-531-6000 ~~=l~CT Intaqro USA Inc.
mg~_Extl: I i~ No: dba Inteqro Insurance Brokers Two Financial Canter ~oMo'fl~ss: 60 South Street, Suite 800
INSURER(&) AFFORDING COVERAGE Boston, MA 02111 NAICt
INSURER A : COLUMBIA CAS CO 31127
INSURED INSURER B : NATIONAL FIRII: INS CO OF HARTFORD 20478 Post Acute Partners, LLC
INSURERC:
and other Named Insureds as scheduled INSURERD: 641 Lexinqton Avenue, 31st floor
INSURERE: New York, NY 10022 ' INSURERF:
COVERAGES CERTIFICATE NUMBER· 40075111 REVISION NUMBER· THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ~~~~~ ~~ ,&~15%~ ,&~M%~ LIMITS LTR POLICY NUMBER
A GENERAL LIABILITY 4022791859 02/01/1~ 02/01/15 EACH OCCURRENCE $ 1,000,000 ~
~~MERCIAL GENERAL LIABILITY ~~~~~~~ ~E~~.;;;!,ncel $ 1,000,000
X CLAIMS-MADE D OCCUR MED EXP (Any one person) $ 5' 000 X incl LTC Prof Liab PERSONAL & ADV INJURY $ 1,000,000
x $1m ea claim/$3m aqq ~~NERALAGGREGATE $ 3,000,000 - ---------------]cj'L AGGR~~~lE LIMI~ Af"'-Js PER: PRODUCTS - COMP/OP AGG _$ INCL.
-----~----~--------
POLICY P,rf'T LOC $
B AUTOMOBILE LIABILITY 4u;.:;.:J~1845 02/01/1· 02/01/15 CE~~~~~~~t SINGLE LIMIT s 1,000,000 "7.-X ANYAUTO BODILY INJURY (Per person) $
- ALLOWNED -SCHEDULED BODILY INJURY (Per accident) $ - AUTOS - AUTOS
NON-OWNED iP~?~:C~,;z,gAMAGE HIRED AUTOS AUTOS $ - x X Comp Coll dad - s I I A l=i ~::::~~:~A~ ~OCCUR ' ' '402279i86;i( 02/01/1~ 02/01/15 EACH OCCURRENCE $ 10' 000' 000
CLAIMS-MADE AGGRE~ATE ------ $10,000,000
OED I X I RETENTION$ 10,000 $ WORKERS COMPENSATION _ltc ST~J;¥5 I jOJ~-AND EMPLOYERS' LIABILITY YiN
IQBYJ.J ANY PROPRIETORJPARTNERJEXECUTIVE D E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A
I (Mandatory in NH) E.L. D~!:;~~~--.!_.0:.§.'~1PLOYEE s Jf yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addltlonall~emarks Schedule, If moro apace lo required)
Evidence of Insurance
Named Insured includes Elderwood Administrative Services, LLC
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE County of Erie and THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Erie Community Colleqe ACCORDANCE WITH THE POLICY PROVISIONS.
4041 Southwestern Blvd. AUTHORIZED REPRESENTATIVE
Orchard Park, NY 14127 fjvvzLd!~ I USA
© 1988·2010 ACORD CORPORATION. All nghts reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD N'; ,.., 1 a q,..nacd:-FnA1""13; n~AI'TY"I'VT1""nnn ,-.nm Rn~
~------· .. ··----~·-···------'
STATE OF NEW YORK WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
ta. Legal Name & Address oflnsured (Use street address only)
ELDERWOOD AT AMHERST 4459 BAILEY AVE BUFFALO, NY 14226-2129
lb. Business Telephone Number oflnsured
212-802-7603
lc. NYS Unemployment Insurance Employer Registration Number of Insured
Work Location oflnsured (0,/yrequiredifcoverageis specifically . I d. Federal Employer Identification !'lumber oflnsured limited to certain /ocatio11s ;, New York State, i.e., a Wrap-Up or Social Security Number
Policy) 90-0775266
2. ~a me and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder)
COUNTY OF ERIE AND ERIE COMMUNITY COLLEGE 4041 SOUTHWESTERN BOULEVARD ORCHARD PARK, NEW YORK 14127
3a. :"'ame of Insurance Carrier
Pennsylvania Manufacturers' Association Insurance Co
3b. Policy Number of entity listed in box "Ia"
0476812A 201375
3c. Policy effective period
12-31-2013 to 12-31-2014
3d. The Proprietor, Partners or Executive Officers are
included. (Only check box if all panners/officen included)
./ all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "Ia" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, :!'lew York (NY) must be listed. under Item 3A on the INFOR.\lATIO:'Il PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Cerntlcate ot lnsuiance to the entity listed above as the cenitlcate holder in box ·-2··.
The Insurance Can·ier will also not if.' the above cenificate holder within I 0 duvs IF a policv is canceled due to 11011pavme111 ofpremiums or ,,·it!Iin 30 days IF there are reasons other than nonpayment ofjJremwms that c.:ancd the po/i,:v or eliminate the insuredji·om theco1·erage indicated on this Certificate. (These notices may be sem by regular maii.J Otherwise. this Certificate is valid for o11e year after this form is appro~·ed by the insurance carrier or its licensed agent, or u11til the policy expiration date listed in box "3c", whichel'er is earlier.
Please /liote: t:pon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is compl)ing with the mandatory co,·erage requirements of the ~ew York State Workers' Compensation Law.
Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced abo,·e and that the named insured has the coverage as depicted on this form.
Approved by: Prathibha Sat1sh
Approved by:
Title: Senior Underwriting Assistant
Telephone Number of authorized representative or licensed agent of insurance carrier: _8_4_7_-_4_0_7_-_5_8_0_3 ___ _
Please Note: Only insurance curriers and their licensed ag,'nts are uutlwri::cd to issue Fom1 C-105.2. Inmrance brokas are NOT autlwri::ed to issue it.
C-105.2 (9-07) www .wcb.state.ny.us
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,,,._,_.,_, __________________ _ STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
la. Legal Name & Address of Insured (Use street address only)
ELDER WOOD AT CHEEKTOWAGA 225 BENNETT RD CHEEKTOWAGA, NY 14227-1528
Work Location oflnsured (0,/y required if coverage is spedjically limited to certain locations in iVew York State, Le., a Wrap-Up Policy)
2. :'1/ame and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder)
COUNTY OF ERIE AND ERIE COMMUNITY COLLEGE _ 4041 SOUTHWESTERN BOULEVARD ORCHARD PARK, NEW YORK 14127
lb. Business Telephone Number of Insured
212-802-7603
, I c. NYS Unemployment Insurance Employer R~istration Number of Insured
I d. Federal Employer Identification Number of Insured or Social Security Number
90-0775265
3a. Name oflnsurance Carrier
Pennsylvania Manufacturers' Association Insurance Co
3b. Policy Number of entity listed in box "la"
0476812A 201375
3c. Policy effectin period
12-31-2013 to 12-31-2014
3d. The Proprietor, Partners or Executive Officers are
included. (Only check box ir all partnen/orlicen included)
.f aU excluded or certain partners/officers excluded.
This cenifies that the insurance earner indicated above m box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (:'1/Y) must be listed under Item JA on the INFOR.\IATION PAGE ofthe workers' compensation insurance policy). The Insurance Carrier or its licensed agent W!!l send this Certificate of Insurance to the c:ntity iisted above as the cenificate holder 1n box "2".
The Insurwrce Carrier will also 11otifo,· the above certificate holder ll'ithin 10 duys IF a polit:J' is canceled due to nonpayment of premiums or lt'ithin 30 days IF there are reasons other thannonpayme/11 u/'premiums that cancel the poli<y ur eliminate the insured from the coverage indicated on this Certificate. (These notices muy he sent hy regular mail.) Otherwise, this Certificate is valid for tme year after thL~form i.~ approved hy the insurance carrier or its licensed agellt, or until the policy e:'Cpiration date /i.(ted in box "Jc", whichever is earlier.
Please :'1/ote: Vpon the cancellation of the workers • compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must proYide that certificate holder with a new Certificate of Workers' Compensation Conrage or other authorized proof that the business is complying with the mandatory coverage requirements ofthe :'1/ew York State Workers' Compensation Law.
L"nder penalty of perjury, I certify that I am au authorized representative or licensed agent of the insurance carrier referenced abo\'e and that the named insured has the coverage as depicted on this form.
Approved by: Prathibha Sattsh
Approved by:
Title: Senior Underwriting Assistant
Telephone Number of authorized representative or licensed agent of insurance carrier: _8_4_7_-_4_0_7_-_5_8_0_3 ___ _
Please Note: On~v msurance carriers and their licensed agems ar~ authori:ed to issue Fo1111 C-1051 Insurance biVkers are NOT awlwri:cd to inue it.
C-105.2 (9-07) www. wcb.state.ny .us
.. •
""'""'""'""-'"" ____ ,,,,,, ,, ______________________________ _
STATE OF NEW YORK WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
Ia. Legal :'1/ame & Address of Insured (Use street address only)
ELDERWOOD AT GRAND ISLAND 2850 GRAND ISLAND BLVD GRAND ISLAND, NY 14072-1251
Work Location of Insured (Only required if coverage i~ specifically limited to certain /ocatio11s in l\'~ York Stote, i.e., a Wrap-l/p Policy)
2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder)
COUNTY OF ERIE AND ERIE COMMUNITY COLLEGE 4041 SOUTHWESTERN BOULEVARD ORCHARD PARK, NEW YORK 14127
1 b. Business Telephone Number of Insured
212-802-7603
I c. ~YS Unemployment Insurance Employer Registration Number of Insured
I d. Federal Emplo)·er Identification Number of Insured or Social Security Number
80-0767547
3a. Name of Insurance Carrier
Pennsylvania Manufacturers' Association Insurance Co
3b. Policy Number of entity listed in box "I a"
0476812A 201375
3c. Policy effective period
12-31-2013 to 12-31-2014 ------------------3d. The Proprietor, Partners or Executive Officers are
included. (Onl~· check box if all partners/officers included)
./ all excluded or certain partners/officers excluded.
This Ct!rti ties that the insurance carrier indicated above in box "3" insures the business referenced above in box "I a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFOR.\IA TION PAGE of the workers' compensation insurance oolicy). The Insurance Carri~ror its licensed agent will se-nd this Certificate ofinsurance lu the entity iisted above .is the certificate hold;r in b~x '"2".
The !ns11rance Carrier will also not if> the above ce11ijicate holder within 10 dars IF a poliC:l! is canceled due to llonpa\'1/lt'll/ of premiums or witili11 30 duvs !F there are reasom other than 11011pt1)ment a( premiums that cancel the poiic,: or eliminate the inmredfrom the coverage indicated Oil this Certificate. rnle.H' notices may be sell/ bv regular mail.) Othern•iu, thi..v Certificate is ~·alidfor Otleyear after this form is approved by tire insurance carrier or its lice1ued agent, tJr 1111til the policy expiration date listed br box ''Jc ", wllidrnJer is earlier.
Please Note: llpon the cancellation of tbe workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must proYide that certificate bolder ~ith a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory conrage requirements of the New York State \\'orkers' Compensation Law.
t.:nder penalty of perjury, I certify tbat I am an autbori;ted representative or licensed agent of tbe insurance carrier referenced above and that the named insured has the coverage as depicted on this form.
Approved by: Prathibha Satish
Approved by:
-:-'{nnt ~a me of authon7.ed rcprcscntattvc or liccnscd agr..."Tlt of insurance carrier)
f/Jt.j;&, ~)k .5{J\( 06/04/2014
Title: Senior Underwriting Assistant
Telephone Number of authorized representative or licensed agent of in~urance carrier: ___ 8_4_7_-_4_0_7_-_5_8 __ 0_3 _____ _
Please .Vote: On(11 inwrance carriers and !heir licemed age/lis are aurlwn::.eJ 10 iss11e Form C-105.2. Insurance hrokc1·s arP NOT authori:ed ro issue ir.
C-105.2 (9-07) www. wcb.state.ny .us
STATE OF NEW YORK WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
la. Legal Name & Address of Insured (Use street address only)
ELDERWOOD AT HAMBURG 5775 MAELOU DR HAMBURG, NY 14075-7419
Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State. i.e., a Wrap-Up Policy)
2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder)
COUNTY OF ERIE AND ERIE COMMUNITY COLLEGE 4041 SOUTHWESTERN BOULEVARD ORCHARD PARK, NEW YORK 14127
lb. Business Telephone :Sumber oflnsured
212-802-7603
lc. :SYS Unemployment Insurance Employer Registration Number of Insured
ld. Federal Employer Identification :Sumber of Insured or Social Security Number
90-0775271
3a. Name of Insurance Carrier
Pennsylvania Manufacturers' Association Insurance Co
3b. Policy Number of entity listed in box "la"
0476812A 201375
3c. Policy effective period
12-31-2013 to 12-31-2014 -------·-3d. The Proprietor, Partners or Executive Officers are
included. (Only (heck box if all pannenioffi(ers in(luded)
I all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated. above in box "3" msures the business referenced above in box ''la" for workers' compensation under theN ew York State Workers' Compensation Law. (To use this form, New York (N\) must be listed under Item 3A on the INFORMATION PAGE ofthe workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of lnsuiancc to the entity hst~d above as rhe certtticate hoider in box ~~2;;. ·
T11e Insurance Carrier ll'il/ also notify the abnl'e ccnificare holder within 10 days IF a policy is canceled due to nonpaymcm a_( premiums or 1vithin 30 days IF there are reasons other than nonpaymem of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (l11ese notices may he sent by regular mail.) Otherwise, this Certificate is valid for o11e year after this form is appro,•ed by tire i11sura11Ce carrier or its licensed agelft, or until the policy e;~:piration date listed in box "3c", whichever is earlier.
Please ~ote: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit,Iicense or contract issued by a certificate holder, the business must pro~;de that certificate holder '1\ith a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory . coverage requirements of the New York State Workers' Compensation Law.
Under penalty of perjury, I certify that 1 am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form.
Approved by: Prathibha Satish
Approved by:
Title: Senior Underwriting Assistant ------~·---- ---
Telephone Number of authorized representative or licensed agent of insurance carrier: _8_4_7_-4_0_7_-_5_8_0_3 ___ _
Plea.~e Note: Onfv inwr-ance curriers and their licensed agems arc aurlwri:cd to issue Fom1 C-105.1. Insurance hrokers arc NOT alllhori::ed to issue it.
C-105.2 (9-07) www. wcb.state.ny .us
. '
STATE OF NEW YORK WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
Ia. Legal Name & Address of Insured (Use street address only)
ELDERWOOD AT LANCASTER 1818 COMO PARK BLVD LANCASTER, NY 14086-2824
Work Location oflnsured (Only required if coverage is specifically limited to certain /ocatio11s in New York State, i.e., a Wrap-Up Policy)
2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder)
COUNTY OF ERIE AND ERIE COMMUNITY COLLEGE 4041 SOUTHWESTERN BOULEVARD ORCHARD PARK, NEW YORK 14127
lb. Business Telephone Number oflnsured
212-802-7603
lc. NYS Unemployment Insurance Employer Re2istratlon Number of Insured
ld. Federal Employer Identification Number of Insured or Social Security Number
80-0767546
3a. Name of Insurance Carrier
Pennsylvania Manufacturers' Association Insurance Co
3b. Policy Number of entity listed in box "Ia"
0476812A 201375
3c. Policy effectiYe period
12-31-2013 to 12-31-2014 --------3d. The Proprietor, Partners or Executin Officers are
included. (Only check box if all partners/orficcn included)
I all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated abow in box "3" insures the business referenced above in box "1 a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or iLs liccmsed agent will send this Certificate ufinsurance tO the entity iisted above as the certificate holder in box ''2". ·
The I11Surance Carner will also notifi.· the abol'e ccn!ficate /wider within 10 days IF a policy is canceled due to nonpayment o(premiwns or ll'ithin 30 days IF there are reasons other than nonpayment of premiums that cuncel the policv or eliminate the imil/redji-om the C'O\'erage indicated 011 this Certificate. (These notices may be sent by regular mail.) Otherwise, tllis Certificate i:nalidfor one year after thL<iform is approved by the uuurance carrier or its /icemed agmt, or until the plllicy expiratio11 date listed i11 box ''3c", wllicl1ever i.~ earlier.
Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Co,·erage or other authorized proof that the business is compl)ing with the mandatory coverage requirements of the ~ew York State Workers' Compensation Law.
Under penalty of perjury, I certify that I am an authorized representatiYe or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form.
Approved by: Prathibha Satish
---·------- -·-· -··-- - -·--
Approved by:
Pnnt name of authorized representative or licensed agent of insurance carrier)
. ' j .• '1.... .-}ik-ll 06/04/2014 (Signature) (Date)
Title: Senior Underwriting Assist"ant
Telephone Number of authorized representative or licensed agent of insurance carrier: _8_4_7_-_4_0_7_-_5_8_0_3 ___ _
Please Note: 011~\' insurance carriers and their licensed agellls are authori=t'd to is.we Fom1 C-105.2. lnmrance brokers are NOT authorized to issue it.
C-1 05.2 (9-07) www .wcb.state.ny .us
STATE OF NEW YORK WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
I a. Legal Same & Address of Insured (Use street address only)
ELDERWOOD AT WHEATFIELD 2600 NIAGARA FALLS BLVD NIAGARA FALLS, NY 14304-4560
Work Location oflnsured (Only required if coverage is specifically limited to certain locadons in New York State, i.e., a Wrap-lip Policy)
2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder)
COUNTY OF ERIE AND ERIE COMMUNITY COLLEGE 4041 SOUTHWESTERN BOULEVARD ORCHARD PARK, NEW YORK 14127
lb. Business Telephone Number oflnsured
212-802-7603
lc. :'Ill'S Unemployment Insurance Employer Rl:listration Number of Insured
I d. Federal Employer Identification Number of Insured or Social Security Number
90-0775263
3a. Name of Insurance Carrier
Pennsylvania Manufacturers' Association Insurance Co
3b. Policy Number of entity listed In box "Ia"
0476812A 201375
3c. Policy effective period
12-31-2013 to 12-31-2014
3d. The Proprietor, Partners or Executive Officers are
included. (Only ch~ck box if all partnenloffic~rs included)
./ all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box .. 3" insures the business referenced above in box ··ta" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (N\) must be listed under Item 3A ~n t~e IN!O~ TION PAG~ ofth.e ~~rk~rs_' compensation ~nsur~nc~ poli~y). The Insurance Carrier or its licensed agent will send ~nts Lerttncate or l!lsurance to tne entlty iistea aoove as tiie certtiu:atc: nojaer tn oox ··..!".
The Insurance CatTier will also not~fy the ahm·e ce11ijicate holder within 10 days IF a policy is ccmceled due to nonpayment of premiums or \l'ithin30 davs IF there are reasons other thannonpavment ofpn71Jiums that cancel tire policy or eliminare rhe insuredfrom the con'!rage indicared on this C erti{icate. f nrese notices may be sem h_v regular mail.) Otherwi,~e. this Certificate is valid for one year after this form is approved by the insuram:e carrier or it.~ lice1uetl agent, tiT 1mtil the policy expiradon date listed in box "3c", whichevtr is earlier.
Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Co\'erage or other authorized proof that the business is complying with the mandatory CO\'erage requirements of the New York State Workers' Compensation Law.
Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form.
Approved by: Prathibha Satish
Approved by:
Title: Senior Underwriting Ass1stant
Telephone Number of authorized representative or licensed agent of insurance carrier: __ 8_4_7_-_4_0_7_-_5_8_0_3 ___ _
Please Note: On~v insurann~ c.:urriers and their licensed agents are awhuri:ed to issue Fonn C-105.2. Insurance hmkcrs are ;\'OT authorized to issue it.
C-105.~ (9-07) www.wcb.state.ny.us
STATE OF NEW YORK WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1 a. Legal Name & Address of Insured (Use street address only)
ELDERWOOD AT WILLIAMSVILLE 200 BASSETT RD BUFFALO, NY 14221-2639
Work Location oflnsured (Only required if col•erage io; .vpecijically limited to certain locations i11 New York State, i.e., a Wrap-Up Policy)
2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder)
COUNTY OF ERIE AND ERIE COMMUNITY COLLEGE 4041 SOUTHWESTERN BOULEVARD ORCHARD PARK, NEW YORK 14127
lb. Business Telephone Number orinsured
212-802-7603
lc. NYS Unemployment Insurance Employer Registration Number of Insured
td. Federal Employer Identification Number of Insured or Social Security Number
80-0767544
3a. Name of Insurance Carrier
Pennsylvania Manufacturers' Association Insurance Co
3b. Policy Number of entity listed in box "Ia"
0476812A 201375
3c. Policy effecth·e period
12-31-2013 to 12-31-2014 ---------3d. The Proprietor, Partners or Executive Officers are
included. (Only check box If aU pannerslofftcers Included)
I all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box "'3" insures the business referenced above in box "Ia" for workers' compensation underthe New York State Workers' Compensation Law_ (To use this form, New York (NY) must be listed under Item 3A on the INFOmtA TION PAGE of the worken' compensation insurance policy). The Insurance C<!_rrier or its licensed agent will send tliis Certificate ofinsurance to the entity listed above as the certificate holder 10 box"::!".
fl1e Insurance Can·ier 11'ill also notifv the abo\·e ceni{icate /wider within 10 davs IF a policv is canceled due to nonpavmt:nt of premiums or H"ithin 30 da.vs IF there are reasultS other than nonpayment of premiwns that cancel the policy or eliminate the insured.from the coverage indicated 0111his Cerri/icute. (fllese notices may be sent bv reRular mail.) Otherwise, this Certificate is ~·alidfor one year after this form is approved by the imurance carrier or its licenud aJ:ent, or u11til the policy expiration date lb,·ted in bo:c "3c", whichever is earlier.
Please Note: Upon the cancellation of the worken' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate bolder, the business must pro,·ide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with tbe mandatory co,·erage requirements of the New York State Workers' Compensation Law.
Vnder penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced abo,•e and that the named insured has the coverage as depicted on this form.
Approved by: Prathibha Satish
( Pnnt name of authorized representative11r licensed agent of insurance carrier I
j) . Jt b 1 ~' 06/04/2014 I' :r (, .u. Li. -~) Approved by: { I Signiture) - (Date) I
Title: Senior Underwriting Assistant
Telephone Number of authorized representative or licensed agent of insurance carrier: __ 8_4_7_-_4_0_7_-_5_8_0_3 ___ _
Please Note: On~v inswance carn·crs and !heir licensed agents are ulllhori:cd to iss11e Form C-105.:!. Insurmu.:t' brokers are NOT awhori:ed to issue it.
c -I 05.2 (9-07) www. wcb.state.ny.us