ecc board of trustees documents/2014_08_28...ecc board of trustees executive summary date: august...

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]

mailto:[email protected]

mailto:[email protected]

..

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 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

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 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 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 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

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

. '

,,,._,_.,_, __________________ _ STATE OF NEW YORK

WORKERS' COMPENSATION BOARD


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


3b. Policy Number of entity listed in box "la"

0476812A 201375

3c. Policy effectin period

12-31-2013 to 12-31-2014


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:



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

.. •

""'""'""'""-'"" ____ ,,,,,, ,, ______________________________ _



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)


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


3b. Policy Number of entity listed in box "I a"

0476812A 201375


12-31-2013 to 12-31-2014 ------------------3d. The Proprietor, Partners or Executive Officers are

included. (Onl~· check box if all partners/officers included)


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


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.




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)



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



3b. Policy Number of entity listed in box "la"

0476812A 201375


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:

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.


. '



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)




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




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)


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:

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


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



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)




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



3b. Policy Number of entity listed In box "Ia"

0476812A 201375


12-31-2013 to 12-31-2014


included. (Only ch~ck box if all partnenloffic~rs included)


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:

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



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)



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




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)


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.


( 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


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

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