FOCUS Packet 2022

FOCUS Packet 2022

Confidentiality Notice

This following documents contain information belonging to Fort Orange Claim Service, Inc. dba FOCUS Adjusters which may be confidential and legally protected. This information is only for the use of the individual or entity to which it was intended. Any disclosure, copying, distribution, or action taken in reliance on the contents of the information contained in this message and any accompanying documents is strictly prohibited. If you are not an authorized recipient of this document please immediate ly delete from your system and contact our office immediately.

Contact:

Patrick L. Young, Chief Operating Officer 635 Plank Road PO Box 447 Clifton Park, New York 12065 (800) 734-2102, Ext. 1903 [email protected] FOCUS Adjusters | Fort Orange Claim Service, Inc.

Emergency Service (800) 488-4215

[email protected] (800) 734-2102

FOCUS Adjusters, proudly headquartered in New York State, is the premier independent (daily and catastrophe) adjusting firm and third party administrator operating throughout the Northeastern United States, Kansas and Florida.

FOCUS offers comprehensive and fully customized loss adjustment programs that are tailored to the specific needs of our clients and their policyholders. Our core-value commitment to traditional integrity based customer service models, unparalleled communication and utilization of InsurTech empowers FOCUS to be the industry leader in our service territories. Additionally, our team has extensive experience with highly complex first and third party claim matters and is a leader in Complex Claim/Large Loss Adjustment, Property Appraiser and Umpire services throughout the entire United States and U.S. Virgin Islands.

EMERGENCY RESPONSE CENTER

24/7

635 Plank Road PO Box 447 Clifton Park, NY 12065 (800) 734-2102 [email protected]

(800) 488-4215 FOCUS Adjusters | Fort Orange Claim Service, Inc.

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DocuSign Envelope ID: 9C1FBDA0-2547-4A53-901A-94B62D18C0D4

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

04/26/2022

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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). 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.

NAME: CONTACT

House

PRODUCER

(A/C, No): FAX

E-MAIL ADDRESS: (A/C, No, Ext): PHONE

Hughes Insurance Agency, Inc. 328 Bay Road PO BOX 4630 Queensbury

(518) 793-3131

(518) 793-3121

INSURER(S) AFFORDING COVERAGE

25666 14508 25615 25038 NAIC #

NY 12804

The Travelers Ind. of America Michigan Millers Mutual Ins Co The Charter Oak Fire Ins. Co.

INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A :

INSURED

Fort Orange Claim Service, Inc Po Box 447

North American Capacity Insurance Company

Clifton Park

NY 12065

21-22 / 22-23 Master

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.

ADDL INSD

SUBR WVD

LTR INSR

(MM/DD/YYYY) POLICY EFF

(MM/DD/YYYY) POLICY EXP

TYPE OF INSURANCE

LIMITS

POLICY NUMBER

1,000,000 300,000 5,000 1,000,000 2,000,000 2,000,000

COMMERCIAL GENERAL LIABILITY

MED EXP (Any one person) PREMISES (Ea occurrence) EACH OCCURRENCE DAMAGE TO RENTED

$

CLAIMS-MADE

OCCUR

$

$

A

680-581M6217-22-42

01/01/2022 01/01/2023

PERSONAL & ADV INJURY

$

GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC

GENERAL AGGREGATE

$

PRODUCTS - COMP/OP AGG

$ $ $ $ $ $

OTHER:

COMBINED SINGLE LIMIT

1,000,000

OWNED ANY AUTO AUTOMOBILE LIABILITY

(Ea accident)

PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person)

AUTOS ONLY AUTOS NON-OWNED SCHEDULED

B

V0509808

06/04/2021 06/04/2022

AUTOS ONLY HIRED AUTOS ONLY

(Per accident)

$

5,000,000 5,000,000

EXCESS LIAB UMBRELLA LIAB

OCCUR CLAIMS-MADE

EACH OCCURRENCE

$

C

CUP-582M0777-22-42

04/26/2022 01/01/2023

AGGREGATE

$

10,000

DED

RETENTION $

$

E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT ER OTH- STATUTE PER

WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE

Y / N

500,000 500,000 500,000

$ $ $

A

UB-6R95436A-22-42

01/01/2022 01/01/2023

N / A

Cyber Liability

D

C4LPY014596CYBER2022

01/02/2022 01/02/2023 Limit /

2,000,000

Retention /

10,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

Subject to all policy terms, limitations and conditions: Certificate Holder is Additional Insured when required by written contract, agreement or permit.

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.

AUTHORIZED REPRESENTATIVE

© 1988-2015 ACORD CORPORATION. All rights reserved.

ACORD 25 (2016/03)

The ACORD name and logo are registered marks of ACORD

DECLARATIONS

Policy Number CP 40948-04

CPLIC Member Services 1883 CR 478

NOTICE

877-572-7542 Myrtle, MS 38650 Coverage potentially provided by this policy is limited to claims first made and reported during the policy period that are the result of wrongful acts committed subsequent to the retroactive date specified in Item 5 of these declarations. Coverage provided by this policy may differ significantly from other similarly named coverage that you currently have or have had in the past. Please review the policy terms, conditions, coverage, exclusions, and claim reporting requirements carefully. In consideration of the payment of the premium, this policy is issued subject to its terms, conditions, limitations and exclusions by Claim Professionals Liability Insurance Company, a Risk Retention Group. This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your state. State insurance insolvency guaranty funds are not available for your risk retention group. Premiums at inception: E & O Premiums $5,389.00 Taxes $202.63 General Liability Premiums Not Covered Taxes $0.00 This policy is subject to audit. NAMED INSURED AND PRINCIPAL ADDRESS Item 1. Insured Name Fort Orange Claim Service, Inc. X Corporation Principal Address PO Box 447 Partnership Clifton Park, NY 12065 LLC Sole Proprietorship Other

Adjusting, investigation, surveying and damage appraisal of claims or losses

Professional

for insurance companies and self-insured entities.

Services Rendered

1/4/2022 1/4/2023 12:01 a.m. Standard Time at the Principal Address stated in Item 1. To:

Item 2.

Policy Period

From:

Item 3.

Limits of Liability (Inclusive of Defense Costs): Errors and Omissions

$2,000,000.00 Per Claim Not Covered Per Claim

$2,000,000.00 Annual Aggregate Not Covered Annual Aggregate

General Liability

$2,500.00 (Defense Costs are Subject to Deductible Amount.)

Item 4.

Deductible Amounts applicable to each Claim

1/4/2004

Item 5.

Retroactive Date:

12:01 a.m. Standard Time at the Principal Address stated in Item 1.

Claim Professionals Liability Insurance Company, a Risk Retention Group

Secretary

President

01/24/22

Forms:

CPLIC Policy (Ed:03/2007)

Issue Date

Page 1

DECLARATION

of Additional Entities and Locations covered by this policy.

Policy Number CP 40948-04

Insured Fort Orange Claim Service, Inc.

No other locations are covered under this policy.

Endorsements 1 No coverage for Cyber Liability in this policy.

Page 2

FORT ORANGE CLAIM SERVICE INC

FORT ORANGE CLAIM SERVICE INC C/O FORT ORANGE CLAIM SERVICE P O BOX 447 CLIFTON PARK, NY 12065

IA-706083 LICENSE NUMBER:

IS LICENSED AS AN INDEPENDENT ADJUSTER FOR

General

BY AND THROUGH THE SUBLICENSEES LISTED BELOW

UNLESS SOONER CANCELLED, SUSPENDED OR REVOKED EXPIRATION DATE: EFFECTIVE DATE: January 01, 2021 December 31, 2022

be affixed at the city of Albany I have caused my official seal to In Witness Whereof,

Shirin Emami Acting Superintendent

Line Key: 1 = Accident & Health 3 = Automobile 5 = Fidelity & Surety 7 = Inland Marine

2 = Aviation 4 = Casualty

6 = Fire

8 = General

9 = Auto Damage & Theft Appraisals

10 = Motor Vehicle No-Fault & Workers Comp Health Service Charges

11 = Federal Multi-Peril Crop

**SUBLICENSEES ARE CONTINUED ON THE NEXT PAGE**

EXPIRATION DATE: IA-706083 LICENSE NUMBER: December 31, 2022 FORT ORANGE CLAIM SERVICE INC

FORT ORANGE CLAIM SERVICE INC C/O FORT ORANGE CLAIM SERVICE P O BOX 447 CLIFTON PARK, NY 12065

SUBLICENSEE(S) CONTINUED

SUBLICENSEE(S) CIURCZAK, STEPHEN G 8

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