555 West 23rd Street Condominium

Insurance Requirements

Please provide the required Certificates of Insurance and Verification of Worker’s

Compensation. See Exhibit A for Insurance Requirements. The Certificates must be issued as
follows:

A. Certificates of Insurance

The following must be listed as additional insured:

• The Unit Owner (include Unit #)
• 555 West 23rd Street Condominium
• The 555 West 23rd Street Board of Managers, individually and as agent for all unit
owners and such other parties specified by the managing agent
• FirstService Residential, Inc., 622 Third Avenue, New York, NY 10017
• Date of the move/delivery

A. Certificate Holder 555 West 23rd Street Condominium

c/o FirstService Residential
622 Third Avenue
New York, New York 10017

B. Worker’s Compensation
Certificate Holder 555 West 23rd Street Condominium
c/o FirstService Residential
622 Third Avenue
New York, New York 10017

If there are any questions regarding these requirements, please contact:

Jared Mosery, General Manager Christopher Ferrino, Resident Manager

Tel: 212-634-5491 Fax : Tel: 212-807-6781
646-786-7180
Email: Jared.Mosery@fsresidential.com Email: rm555w23@gmail.com

Email or Faxed copies are acceptable initially but originals must be mailed afterward and
received before any work commences.

Correctly issued Certificates must be submitted a minimum of 72 hours prior to the work or
delivery. Scheduling must be arranged with the General Manager or Resident Manager in
advance.
EXHIBIT A
 DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 01/01/20--__
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 policy(ies) 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(s).
PRODUCER CONTACT
NAME:
PHONE FAX
(A/C, No, Ext): (A/C, No):
BROKER E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #

INSURER A : INSURANCE COMPANY NAME 20281

INSURED INSURER B :

CONTRACTOR & OR SUBCONTRACTOR INSURER C :

ADDRESS INSURER D :

NY INSURER E :

INSURER F :
COVERAGES CERTIFICATE NUMBER: 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 ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 1,000,000
A POLICY NO. 1/01/01 1/01/01
CLAIMS-MADE X OCCUR MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
PRO- $
POLICY JECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ea accident) $ 1,000,000
BODILY INJURY (Per person) $
A ANY AUTO
ALL OWNED SCHEDULED POLICY NO. 01/01/01 01/01/01 BODILY INJURY (Per accident) $
AUTOS AUTOS
X X NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
$

X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000

POLICY NO. 01/01/01 01/01/01
A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000
DED RETENTION $ $
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS' LIABILITY TORY LIMITS ER
Y/N POLICY NO. E.L. EACH ACCIDENT $ STATUTORY
ANY PROPRIETOR/PARTNER/EXECUTIVE N/A
OFFICER/MEMBER EXCLUDED? 01/01/01 01/01/01
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ STATUTORY
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ STATUTORY

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
The Following are named as Additional Insured:
FirstService Residential New York, Inc. as managing agent, 555W23 Condominium Condominium

555W23 Condominium –555 West 23rd St., New York, NY 10011

Unit Holder Name: Unit#

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
555W23 Condominium
c/o FirstService Residential New York,
AUTHORIZED REPRESENTATIVE
Inc. 622 Third Avenue, 14th Floor
Attn: Insurance Coordinator
New York, NY 10017

ACORD 25 (2010/05) © 1988-2019 ACORD CORPORATION. All rights reserved.

INS025 (201005).01 The ACORD name and logo are registered marks of ACORD