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HomeMy WebLinkAbout13-2757 Su Co of Pennsylvania Coul l 011,111110H leas For Ps-oticoiaolwy �• CoAii . I' S `et Docket No: ('TI :RFRT, �1 Coun The information collected on this,forn is used solely for' court adfninistl•ati6n proposes. This form does. not nippleniew ot• re lace the filing and service ofpleadings or olhef° aa' eP•s as Peguii-ed b y 1mv or rules of court. „ Coil] netcernient of Actlon: S C 0 omplaint Q Writ of Sun ]nnons 0 Petition ransfer from Another Jurisdiction E] Declaration of Taking 1. E ' C Lead Plaintiff's Name: DONEGAL MUTUAL INSURANCE L ead D efendant's Name:HUGHES CONTRACTING, INC. COMPANY and ATLANTIC STATES ;T - - I Yes No Are money damages requested? ( Dollar Amount Requested: '. , ithin arbitration limits 1. (check one) Doutside arbitration limits rO. N is this a Class Action Surit? [ Yes No Is this an AffiJAppeal? Yes eNo A Name of Plaintiff /Appellant's Attorney: Amato and Lessa, P.C. i `J' Check here ifyou have no attorney (are Self-Represented {Pro Se] Litigant) Nature of the Case Place the left of the ONE case category that most accurately describes your PAIIMART' CASE. If you are making more than one type of claim, check the one that you consider most important. TORT (do not include Mass Tort) CONTRACT (do not include Judgments) CIVIL APPEALS ` El Intentional [3 Buyer Plaintiff Administrative Agencies a� Malicious Prosecution 7 ebt Collection: Credit Card I_ i Board of Assessment v� Motor Vehicle Webt Collection: Other ❑ Board of Elections Nuisance Dept. of Transportation Premises Liability j Statutory Appeal: Other 5 Product Liability (does not include -� Employment Dispute: � M(JSS tort} a �a Slander/Libel /Defamation Discrimination C ? Other: Employment Dispute: Other Zoning Board T Other: other: MASS TORT Asbestos Tobacco 0 Toxic Tort - DES - ,4 Toxic Tort - Implant REAL PROPERTY MISCELLANEOUS Toxic Waste �i Other: 13 Ejectment Common Law /Statutory Arbitration B 0 Eminent Domain/Condenunation 0 Declaratory Judgment �] Ground Rent 7 Mandamus Landlord/Tenant Dispute Non - Domestic Relations +' El Mortgage Foreclosure: Residential Restraining Order PROFESSIONAL LIABLITY Mortgage Foreclosure: Commercial Quo Wa►ranto Dental Partition Replevin Legal Quiet Title Other: E3 Medical 0 Other: Other Professional: Upd4ded 1/1/2011 1 i COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW DONEGAL MUTUAL INSURANCE COMPANY and ATLANTIC STATES , + Plaintiff No. V c_..� -' v.5. M q HUGHES CONTRACTING, INC. r te— _� T CIVIL ACTION Defendant v 7 c7 c:) "'7 CD c s Uri NOTICE YOU HAVE BEEN SUED IN COURT. IF YOU WISH TO DEFEND AGAINST THE CLAIMS SET FORTH IN THE FOLLOWING PAGES, YOU MUST TAKE ACTION WITHIN TWENTY (20) DAYS AFTER THIS COMPLAINT AND NOTICE ARE SERVED, BY ENTERING A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILING IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH..AGAINST YOU. YOU ARE WARNED THAT IF YOU FAIL TO DO SO THE CASE MAY PROCEED WITHOUT YOU AND A JUDGMENT MAY BE ENTERED AGAINST YOU BY THE COURT WITHOUT FURTHER NOTICE FOR ANY MONEY CLAIMED IN THE COMPLAINT OR FOR ANY OTHER CLAIM OR RELIEF REQUESTED BY THE PLAINTIFF. YOU MAY LOSE MONEY OR PROPERTY OR OTHER RIGHTS IMPORTANT TO YOU. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249 -3166 AMATO AND LESSA, P.C. By: C Michael R. Lessa, Esq., Atty ID #88617 David A. Lovejoy, Esq., Atty ID 419829 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Paul F. Troisi, Esq., Atty ID #309511 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866 -0400 A DEBT COLLECTION LAW FIRM S� � COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION;' LAW DONEGAL MUTUAL INSURANCE COMPANY and ATLANTIC STATES INSURANCE COMPANY Plaintiffs No. VS. HUGHES CONTRACTING, INC. CIVIL ACTION Defendant COMPLAINT The above Plaintiffs bring this action against the above Defendant to recover the sum of $26,397.74, with interest thereon as hereinafter stated, upon the following cause of action: 1. Plaintiffs, DONEGAL MUTUAL INSURANCE COMPANY and ATLANTIC STATES INSURANCE COMPANY, are located at 1195 River Road, Box 302, Marietta PA 17547 -0302. 2. Defendant, HUGHES CONTRACTING, INC., is located at 1787 Trindle Road, Suite 801, Carlisle PA 17015. COUNT Breach of Contract 3. At the request of Defendant, Plaintiffs issued various policies of insurance, with policy numbers as shown on Exhibit "A ", naming Defendant as the insured, true and correct copies of the declarations pages of which are attached hereto, made a part hereof and marked Exhibit "A- 1 " through "A -6 ". 4. Pursuant to the terms and conditions of said policies, Defendant was required to pay earned premiums based upon Defendant's actual payroll and /or audit results for the policy periods. 5. However, the policies were issued to Defendant based upon an estimate of Defendant's payroll and/or audit results for the policy periods and, therefore, the original premiums quoted under the policies were also an estimate. 6. Defendant received and accepted the insurance coverage under the subject policies. 7. Subsequent to the termination of the policies, Plaintiffs conducted an audit of Defendant's business records to determine Defendant's actual payroll for the policy periods. A true and correct copy of the results of the audit is attached hereto, made part hereof and marked as Exhibit "B." 8. Based upon Defendant's actual payroll for the policy periods, Defendant was required to pay earned premiums in the amount of $38,621.00 for the aggregate policy periods, all .of which were calculated in accordance with the policies. 9. However, Defendant has failed to pay earned premiums in the amount of $25,713.00, as set forth in the statement attached hereto, made part hereof and marked Exhibit "C." 10. Defendant's failure to pay all earned premiums due Plaintiffs for the extension of insurance coverage under the policies constitutes a breach of the policies. 11. Plaintiffs have performed and complied with all terms and conditions required under said policies. 12. Plaintiffs are entitled to receive interest on the above amount determined by applying the statutory interest rate of 6.00% per annum to the past due balance. As of March 5, 2013 the total amount of interest due to Plaintiff is $684.74. 13. Plaintiffs are entitled to have the 6.00% interest charge continue to accrue as set forth above, from March 5, 2013 on down to the date of judgment in this matter. 14. Plaintiffs have made demand against Defendant for the aforesaid sum, but Defendant has failed or refused to pay the same or any part thereof. WHEREFORE, Plaintiffs demands judgment against Defendant for $26,397.74 together with the continually accruing interest charge at the statutory rate of 6.00% per annum from March 5, 2013, costs of suit and all other relief to which Plaintiffs are entitled. COUNT II Alternative to Count I - Unjust. Enrichment 15. Plaintiffs incorporate the allegations of every paragraph enumerated above of this Complaint as if said paragraphs were fully set forth here at length. 16. At Defendant's request, Plaintiffs conferred a benefit upon Defendant by providing the insurance services described in the exhibits attached hereto. 17. Defendant received and accepted the benefit of said services provided by Plaintiffs. 18. At all times material hereto, Defendant was aware that Plaintiffs were providing the aforesaid services to Defendant and that Plaintiffs expected to be paid for such. 19. At all times material hereto, Defendant, with the aforesaid knowledge, permitted Plaintiffs to provide said services and to incur damages. 20. At all times material hereto, Defendant was unjustly enriched by retaining the.benefit of receiving said services without paying Plaintiffs fair and reasonable compensation. 21. Allowing Defendant to retain the benefit of said services without paying fair compensation would be unjust. 22. By reason of the aforesaid unjust enrichment of Defendant at Plaintiffs' expense, an implied contract exists between Plaintiffs and Defendant and Defendant is obligated to pay Plaintiffs the quantum meruit value of the services described in the exhibits attached hereto in the amount of $25,713.00. WHEREFORE, Plaintiffs demand judgment against Defendant for $25,713.00 together with the continually accruing interest charge at the statutory rate of 6.00% per annum from March 5, 2013, costs of suit and all other relief to which Plaintiffs may be entitled. AMATO AND LES A, P.C. By: Michael R. Lessa, Esq., Atty ID #88617 David A. Lovejoy, Esq., Atty ID #19829 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Paul F. Troisi, Esq., Atty ID #309511 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866 -0400 A DEBT COLLECTION LAW FIRM VER11F1QATIO.N, Dan J. Wagner, CPA hereby states that hele is the Sr. VP. & Treasu Donegal Mutual Insurance Company of Plaintiff in this action, and verifies that the statements made in the attached document are true and correct to the best of his /her knowledge, information and belief. The undersigned understands that the statements herein are made subject to the penalties of 18 Pa.C.S.A. § 4904 relating to unsworn falsification to authorities. Daniel J. W gher CPA Sr. Vice Presid t & Treasurer • polk,-:':.. .i3�`3o.', •: ;.:..•:. >. :." .. ': ERCIAL . TO'POLICY; >DECLARATIONS . ... C..OVERAGE<IS?PROYIDED!'BY DOfd1GAL>VIU'Y`I�AL <INSUR/�NCE; 1T EM ...... . ...::.:..:.:..:::::::POLICY NUM..BER. ..: :..:..:..::... .::..::....:.:::.::::.... :..:...,:...:.....::..::.. >...: ,::....... C..'' .. .........::. : ...;: ' <. ;: <::: > >.:::<, >:.., •.' >?:::::: >?..::. >:<`:: °° °:': w:;:;: :,� � ::::::::' ..::::::::::::::..::;7< �' unhl itsurarce ::; { . >:: > :;.:,,:= ..:'hlu hes�Gonttactln.g:;inc. R...D..... .....:.:::.... ...::........:...... . T. dle..Rd... 1..7.87.. n ..............::.. .........:....:.: ...::..:......:::..:::<.; .., ........... :....,..:.: :':::. ........ ...... <:';': #::'786-0 : 70::>;; r.: p::<; E` r �: �> > >:; ::::'::.::.::�::�: :•:;� >.;: ;; ::::.< ;';::.. . :.::.. ED:: INS. URED: S:>:'.:..>;:::::.:<:::':: �::::?:::':'::"• .'s >:,:,':::;<..: >'.::�'< ?:•'': .;::. >:.::; :..:;;:::::::;<:: >::::;:: : :: ..'.•' � ' :'..> :...: . :.:.:..... :.:.... .. .... NAMED :IN�UI�1= �'S:�CISINESS.:....... ,.,....,..:.. POLICY :• s[` D Cef ent:. : ': `ri� °>'` � : "idsri:.'::.: <`: ".r °�'r.'::'': r'r'FROM Z ::101OT: - .::1:�>:: ?.:. 1fd101l20T:2' :: ;•:.::> ::. ' ,.:::::'." ......:.: .............:......... :.... AMED 01 : A: lUI:; I NDARDTIME '.JC7T}lE::`:;::;.::: ::': .t:::;; . .::....: ...::)):: >: >::;: ; :;:s:: <:::;•> :: :> ss N`:: IN REM IN :RETURN f..OR7#1E> ".P AYI�IENTOF..:THE; PREMIUM AND:SIJBJECT7Q AtLYfIE'TERMS OF THIS. POIIGY ^:V1IEkGREE YVi1 W YOU:T.O' ?:;; :::::: ?; ° '•. ;`: RdV U NGEAS ?$3'' D1N:7HI5Pb: Ibi= "tF1E`IN$ P RA ATE LiGY.:: :>'.°?<° r>: z'' r": E '?['' E �' �' �'[<:'° r: ::>'::?':'>'::::; . :<::'"':.:>''>>::>.;.?' •,_:;_' c> :: > :: :p<:'s: >i' `.''r € °':r:: " >::r:.: .......... ..: . � R 3 OCJ:': HAVE ;PU3tC8ASBDOI;LI5YN1;C0%'EItAGE IJI!TDSR;THIS. POI; ICS ';IsOIiHIREDATITOS:TAIS. 35 ROYIDE> COVERAGE' ?' <'..:> FOR'COLii ISION: DA�YIAG�ETC1�l1Y. AUt� CASbEI- NED�f !1`YO.URPOIi RENT. TI '#1SCO�EGE'M YBE::. :''.:..'•.': :'OH$R A YAIT�ABLE 1NSUItANCE.1F EXCESS OVER T Y OSS Ot� TIJ►VE �iti COT.L"ISIOI�T L'WIT#i TBE, lO IREN3'idD Ai3;C0 i ` .:: ,: >i: . :; HAVE'I O pA f' fiH$;I:OW$ST; OLLISiON.DEIIUCY'YBI.E AMOiT1�tT AI'PLlCABT E'I'O ...... TT COLI ISI()N CifVEitAGE: -'::BECAUSE TFIERE ARE MANYDLF+'•ERENT AJTO RItNTAT. Ci)NTRACTS, A YbU:9Ii0ULD BAD; SUCHCONTRi1CT5t ?::'::':.;:;;:.':': [ : CAIiEF[1 LLY�$ EFOREREJ' Fi(. T. IrT( sG�I+ LI, SI (ONDJINIA( 01 FERBD: B�1� .ATO,R�+iN1'AI:AG$PICY.;: > EYOUR POY:3CY:YNCL,UbING I AY.Y. �NDbRS�M$NCS' ATTACH�,D T(3'AN�317AD� : 'A P . T':QF.S"[IG'H, PUT. ICY.. AND,`, i :::::.:;: :.;..'r <;': •R VI'EwxYOUR I)E TONS I'�G$S<I:OI*s.GOYVIPT; �` • : . , GEb E. ... C.LARA .. ... _.. E �.COYEIfA ..... �' Y' ALL�S:';•:::::.::.;:;:: ::;.;- �: >:`:::[:<: ;:< >:•;,;;,;; ... ..:.:.............. ..........:::: : <IrM EXHIBIT BIT 01 :.......::.. . , .. :........:.. .......: .. r: B J .:.:...... ...::.....:::.::... ....:.:.: . : ..:....:..... ...:..:.::... ' .........: r. �:':.:.::;:.: :...:::..: .....:.... :.:..':. .: resl�ent 07::0 t DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547 -0302 PAGE 2 COMMERCIAL AUTO POLICY DECLARATIONS POLICY NUMBER: CA 8063414 ITEM TWO: SCHEDULE OF COVERAGES AND COVERED AUTOS - This policy provides only those coverages where a charge is shown In the premium column below. Each of these coverages will apply only to those "autos" shown as covered "autos ". "Autos" are shown as covered "autos" for a particular coverage by the entry of one of more of the symbols from the COVERED AUTOS Section of the Business Auto Coverage Form next to the name of the coverage. ...LYY. : 7 . `•)y;, ;Y y:. -,3,.{ i > 2' i : f R: Y:;x:): ;2 #i ?;'( ^�. : ..`.,.,. ,:•'':;� % .�;,:�.: u�':t1 .. �? . ..egRr••a; �Z � �' •'�;Y,..xt� :.�„ .� t��l ••. v: h•:: K. >ti...,:t� `kt - � "' a,r.:w 's. s „, +'Ci < - :y:.� : :.M ; t a.4 »;x. ^t, • .mss.. :..:... #V:x ?I .•.:.,: �� � .. ” i,. w: � # � �.�• , .�L.'!?M...'%X:fi Y : ���:?hSA: .. ? � : 4� � .,�', : S: ;• .y Yv1t >:,.. {.S: f';:;....,,{C�':..., .5 #, .. :Y:f G #+Cy.'rr' X3'£�' a c , vYx::•,Y . €:; .:"^u�£iJ :tY• . ? ry .,,.',`..ic c Y.c.:, :..,., LIABILITY 1 S1,00o,000 EACH ACCIDENT $2,144 LIABILITY DEDUCTIBLE NotAppllcable PERSONAL INJURY PRO CTION 5 AS STATED IN THE SUPPLEMENTAL DECLARATIONS $344 (Or Equivalent No -Fault Coverage; MINUS THE DEDUCTIBLE SHOWN IN ITEM THREE. Basic First Party Benefits In Penn Ivan la ADDED ERSONAL INJURY 5 ASS TED IN THE SUPPLEME AL DECLARATIONS. Included PROTECTION (Or Equivalent No- Fault Coverage; Added or Combination First Party Benefits in Pennsylvania MEDICAL EXPENSE Coverage INCOME No COVe ASSTATED THE SUPPLEMENTAL DECLARATION . No Coverage LOSS BENEFITS (Virginia only) AUTO MEDICAL PAYMENTS No Coverage AS STATED IN THE SUPPLEMENTAL DECLARATIONS. No Coverage UNINSURED MOTORISTS 2 AS STATED IN THE SUPPLEMENTAL DECLARATIONS. $181 UNDERINSURED MOTORISTS 2 AS STATED IN THE SUPPLEMENTAL DECLARATIONS. $220 (When not Included In Uninsured Motorists Coverage) PHYSICAL DAMAGE 7 ACTUAL CASH VALUE OR COST OF REPAIR WHICHEVER IS LESS, $104 COMPREHENSIVE COVERAGE MINUS THE DEDUCTIBLE SHOWN IN ITEM THREE FOR EACH COVERED "AUTO ", BUT NO DEDUCTIBLE APPLIES TO LOSS CAUSED BY FIRE OR LIGHTNING. See ITEM FOUR -For Hired Or Borrowed "Autos'. PHYSICAL DAMAGE SPECIFIED No Coverage ACTUAL CASH VALUE OR COST OF REPAIR WHICHEVER IS LESS, No Coverage CAUSES OF LOSS COVERAGE MINUS THE DEDUCTIBLE SHOWN IN ITEM THREE FOR EACH COVERED "AUTO ", BUT NO DEDUCTIBLE APPLIES TO LOSS CAUSED BY FIRE OR LIGHTNING. See ITEM FOUR For.Hlred Or Borrowed "Autos". PHYSICAL DAMAGE COLLISION 7 ACTUAL CASH VALUE OR COST OF REPAIR WHICHEVER IS LESS, $347 COVERAGE MINUS THE DEDUCTIBLE SHOWN IN ITEM THREE FOR EACH COVERED "AUTO ". See ITEM FOUR for Hued or Borrowed "Autos". PHYSICAL DAMAGE TOWING AND No Coverage For Each Disablement Of A Private Passenger "Auto ". No Coverage LABOR PREMIUM FOR ENDORSEMENTS MISCELLANEOUS TAXES, SURCHARGES AND FEES (If applicable see Supplemental Declarations. , /... !. 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CL:4'(!1%iJl;);.1111111111111111�11111 ---IIIIIIIIIII--! .,/ DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547-0302 PAGE 2 POLICY NUMBER: CPAS063414 jy'� .11:��M:a O. ::i1F... 1�`�I•, v .K. i .a�ft.Mf•.M. .�wl� u}:.:nw:•:.•.a.. ...{..x::::.:a•.n......}......a n.....\..}�.. v.:C}u}E?:vfii COMMON POLICY FORMS AND ENDORSEMENTS ARE APPLICABLE TO ALL COVERAGE PARTS,UNLESS OTHERWISE STATED IN THE FORM OR ENDORSEMENT. I CMOF-600(01-08) Policyholder Disclosure Notice Regarding Terrorism Insurance Coverage I IL 00 03(04-98) Calculation of Premium IL 0017(11-98) Common Policy Conditions IL 00 21 (04-98) Nuclear Energy Liability.Exclusion Endorsement Broad Form IL 0166(01-99) Pennsylvania Changes-Actual Cash Value Endorsement IL 0172(11-93) Pennsylvania Changes IL 02 46(09-00) Pennsylvania Changes- Cancellation and Nonrenewal IL 0910(01-81) PA Notice-PA Insurance Cancell.SeN Exemption Act PAYMENT PLAN: Account Billedlren Pay President 08/22/11 07:09:96 � � DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547-0302 PAGE 3 POLICY NUMBER: CPASOS3414 Commercial Property Coverage Part Declarations •.li' :./.o< ..::i:i'f:;. '+F:ti: ./:. irF:''✓.K:Y•::::t:i+ :..:e:%%Y:r.:� :.r.: ..!%if:`F:o:Fi:GF:•'.>ifri•:iFiF::; o:f .i>Y;ri..;/ F2r.::ffia: i....s,�i'ft::;f;,;•}.... ..r.r.::w%i:,Y�i�'F , •:."}•i:^:.ifG. "•?:✓:i'r':`:f'i:f:,MU..:, .uy.C�r.�,;r":;:;ii'. s:' Gi1iX1i: �C.�+iSvS,1,;,,,/ -a.r.+..:Yr/':.�,�.:�:£�,l.t::zs.,.f. r Fr.•!`p:`4vn:uyr•.^.'n;;:::/...>:..rf, :.� ...r.c.....,.::.w<>.al:x:::w....�:or 4::.Y.•C:.F r 7. ::r:n...:..!......;:y:::;r.F?f:;" :.�.. :G't%'lA4? >:S.t I%F i':'S%'c'''ik�.::w PREMISES 1; BUILDING 1: 14 Cardinal Dr, Carlisle PA 17015 OCCUPANCY: Carpentry COVERAGES BUSINESS PERSONAL PROPERTY INCL. INFLATION GUARD: N/A STOCK LIMIT: $5,000 DEDUCTIBLE: $500 COINSURANCE: 80% VALUATION: Replacement Cost COVERED CAUSE OF LOSS: Special Incl.Theft TOTAL COMMERCIAL PROPERTY PREMIUM AT DESCRIBED PREMISES: ::.:.�..:.."%'...:..:::..:v:::::.>YY:t�::Y.r:..y:;:Y':.;.:;,•,/: .�::.:J i..;.:.y:::l:Y�:.:;:.:�::v:::...::.�.;•;:;:;.:v.;�::.:F i:::t.Y: ::rv.::::1:r:Y. ....:...':..,i.. •.:.r.,.f•:.... ,1.: .,/ .t./,..�ax:.� br..u.: ::./. .r. //:: :.+/.:.: Yai u•I %•Y'YY:a r:Nfp•./yi.,t,..�y...:yrF,..fir: :.n>J.,.,n!f•:::.//+.jt:':.:::. �.::.FiY.:f,'i" :{Y:%:ff%.. 7'�Sff;: . 6 YF.St,2: fY f ;F� ..,.r; :;'ii.,;?•r; � r'/ /rf frrr/ t / / � ��-.. k �y �p/�r Mff./n )r.% $n ��> tl:,f�. +ir /f lff.�:.`•::% l rJ �L?. �r �y /:;i• ,t iF:i/•G:>y:'v':.L:::v .r �o r :!!ffi" ,r ./: r r/ ,Gr� .F'Ft+Cf r•!5:..,. .:r;::.?'.-C:..:.!.... 7/......:. //r•n::...,....:..t.ri li+.�L �R`:,.:.,::.w.{.r:/..'laso+<:r:,:,.f:✓•....::.:.:;.rf:r.`.r,�>.:5:.+.:�1:"/:.?i:: ./!/,• RC. +.r. /. PREMISES 2; BUILDING 1: Ste 801, 1787 Tdndle Rd, Carlisle PA 17015 OCCUPANCY: Carpentry COVERAGES BUSINESS PERSONAL PROPERTY INCL. INFLATION GUARD: NIA STOCK LIMIT: $7,500 DEDUCTIBLE: $500 COINSURANCE: 80% VALUATION: Replacement Cost COVERED CAUSE OF LOSS: Special Incl.Theft BUSINESS INCOME WITH EXTRA EXPENSE COINSURANCE: No Coinsurance AND RENTAL VALUE LIMIT: $7,500 COVERED CAUSE OF LOSS: Special Ind.Theft VALUATION: Agreed Value does not apply TOTAL COMMERCIAL PROPERTY.PREMIUM AT DESCRIBED.PREMISES: CP 0010(06-95) Building&Personal Property CP 00 30(06-95) Business Income and Extra Expense INCL CP 00 90(07-88) Commercial Property Conditions CP 10 30(06-95) Causes of Loss Special Form CPD 90 03(08-05) Biological And Chemical Contaminants Exclusion With Limited Exception For Certain Fire Losses CPD 906(11-00) Silver Series Plus Property Coverage Enhancement $225 IL 09 35(07-01) Exclusion of Certain Computer-Related Losses ILD 09 52(01-08) Cap On!Losses From Certified Acts of Terrorism Presldent 08/22/11 07:09:46 DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547-0302 PAGE 4 POLICY NUMBER: CPA8063414 .:: .$ sin ..Zv..a.. ' ,N.h. •tiMi•dCi.`':tE,.: i;?5...,:'+�n':`rt :sb:J:.. >h 3,•k;dc ':�`+{ r`:-:. ?.Y�k\ ^�Sns.£.::. :�•`.i;' :..k>. l,•p:.y µ+KGtx.M-`lii� : Y'�5'1�`•''^ '•�f.II` <••K<r:,. ,�>,:<:;{;,„,.Y;k:Y:�.i v��' .k::�.Y.{.K:�,.: .:. �..� :'- :. .:� .�:..:,..��� ., ,.s �......�J�k 342 :r.; 't •.•�.� ,,.x,.,, ..k .c.stw�;:2:{e :,:.<..YY?::.<w<Y.{^;.o::<:.�etiw. �cz:{;,w...,,.,:Y��bk':��ai'#aiY>L::':v»:w< - k .84.b ..2i::£;:{'S•u::�;:tY): :iEg:S:a r .w... b,co Commercial Property Form,Coverage and Endorsement Supplemental Information 'Kv -;i{- s•b ::xxw. {dC.J.Y:^:vf.:: :`\ .0".°` .:tk:<:?;:i{.^' • ,�,. ;t;silN '�IYIitS.T,{i Jn` S fl/��Y..~K�l�� :'�1::,!,.,S{;}:\.-\\:.,,<t: v:t1��\{T.; k,, yp>:.k}'.\>:Y6>v �.^b.a.87�CLfi�i::::•5%kt\A,��•.\'.i:.i:�#�uq.,^.kn(S{.�$�..�,4ivtvQvl�:':v..,w:\ii: Covera a Limits of Insurance. Dedactib s Page Accounts Receivable Coverage Extension $25,000 Applicable Your. 20 Business Personal Property Deductible Arson,Theft and Vandalism Reward Additional $5,000 None 3 Covera e Brands and Labels Additional Coverage $10,000, None 3 Broadened Building Coverage Included in applicable Applicable Building 1 Building Limit of Deductible Insurance Broadened Debris Removal Additional Covera a $25,000 -None 2 Broadened Fire Department Service Charge $2,000 None 2 Additional Coverage Broadened Newly Acquired or Constructed Property $500,000 Highest Building 17 Coverage Extension-Building Deductible Shown In Declarations Broadened Newly Acquired or Constructed Property $250,000 Highest Your 18 Coverage Extension-Your Business Personal Business Personal Property Property Deductible Shown In Declarations Broadened Outdoor Property Coverage Extension- $5,000 Applicable Your 18 Antennas,Trees,Shrubs and Plants Business Personal Property Deductible Broadened Outdoor Property Coverage Extension- $10,000 Applicable Your Fences,Signs and Retaining Walls Business Personal Property Deductible Broadened Personal Effects and Property of Others $25,000 Applicable Your., 19 Coverage Extension Business Personal Property Deductible Broadened Personal Property In Transit Additional Highest Your 25 Occurrence Coverage Extension Occurrence Per Business Personal O $25,000 Policy Year Property Deductible Shown In Declarations Broadened Pollutant Clean Up and Removal $25,000 None 3 Additional Coverage Broadened Preservation of Property Additional Included in applicable None 2 Coverage(90 days) Building and/or Your Business Personal Property Limit of Insurance Broadened Property Off-Premises Coverage $25,000 $250 19 Extension Building Ordinance or Law Additional Coverage- Included in applicable Applicable Building 4 Loss to the Undamaged Portion of the Building Building Limit of Deductible Insurance Presideni 08/22/11 07:09:46 04 DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547-0302 PAGE 5 POLICY NUMBER: CPA8063414 "in Vii+ 4. •2 Coverage Limft a of Insurance Deductibles Page Building Ordinance or Law Additional Coverage $50,000 None 5 Demolition Cost and Increased Cost of Construction Business Income and Extra Expense Additional $25,000 72 hours 6 Coverage Business Income and Extra Expense Additional Included in Business 72 hours 7 Coverage-Alterations and New Buildings Extension Income and Extra Expense Limit of Insurance Business Income and Extra Expense Additional Included in Business 72 hours 7 Coverage- Civil Authority Extension (3 weeks) Income and Extra Expense Limit of Insurance Business Income and Extra Expense Additional Included in Business 72 hours 7 Coverage- Newly Acquired Properties Extension Income and Extra Expense Limit of Insurance Deferred Payments Additional Coverage $5,000 Applicable Your 10 Business Personal Property Deductible Employee Theft Additional Coverage $10,000 $250 10 Fine Arts Coverage Extension $10,000 Applicable Your 21 Business Personal Property Deductible Fire Extinguishing Equipment Recharge Additional $5,000 None 13 Coverage Glass Additional Coverage Extension Included in applicable Applicable Building 27 Building Limit of Deductible Insurance Installation Coverage Extension $5,000 Highest Your 22 Business Personal Property Deductible Shown In Declarations Inventory and Appraisals Additional Covers a $5,000 None 13 Lock and Key Replacement Additional Coverage $1,000 Per Applicable Building 14 Occurrence Deductible $5,000 Policy Year Money and Securities Additional Coverage- $10,000 $250 14 Inside the Premises Money and Securities Additional Coverage- $10,000 $250 Outside the Premises Personal Property At Exhibition Coverage Extension $5,000 Highest Your 22 Business Personal Property Deductible Shown In Declarations Salespersons Samples Coverage Extension $10,000 Highest Your 23 Business Personal Property Deductible Shown In Declarations �President 08/22/11 07:09:46 DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547-0302 PAGE 6 POLICY NUMBER: CPAS063414 ....<Uy:.:i0.:'•'\vJ};•:W}:vi:•}}:i:•:"•nO::iCCri..IX' '•:iii"[Y:v }:J:i•:iti ::\:•}:. }:}?:: v::J:'v C•8:' :.h:v ;S :: .: '::i`:k.y E`+;?:'i;;a>::a 'i;%:,,.kt?.•;a,is;kh:1 .Y;fk: < .. : �k� Vii;. . ;; `• i{l�;.: � : rnl�i�#;� ;,3,s<�aa �•'::c :.>.:,<;,: : Coverage Limit(s) of Insurance Deductibles Page Tenant Glass Additional Covers a $10,000 $250 16 Valuable Papers and Records Coverage Extension $25,000 Applicable Your 24 Business Personal Property Deductible Water Backup of Sewers,Drains or Sumps Additional $10,000 Applicable Your 17 Coverage Business Personal Property Deductible President 08/22/11 07:09:46 DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547-0302 PAGE 7 POLICY NUMBER: CPAS063414 Commercial General Liability Coverage Part Declarations ....!y:. }tt°., :'7.!.':%R'/ {1.. .,.•f!?::,yam•y:,/..} ;':i<:.:!�,, ::•f•f (�:::}}. •;R':. r,G,x :!%` .:t}o..:;o!: ..I: H...:� k.u::'.:;C'•.:�i ��!!.n<.�f.'1�'?�' v }.). vh•f..r.:ih!'��L l.{.i'r'rr %{�r. 3•}}::.gli' ...tt':.aF,Y. LL .E1 i.v�42 Ai:?::'i.�:::.: �.{:u.� �Ti.:.:v%..,N./)'Y.:: "%:l.<'f1!.:}. .;<!?'.;iS ti.`•gg;,:.•,.::.,...f':„�:%.:.<�/'.i,.•:::., x,.. i'!W:s:,n,Y.:,;r'r 5r?}' .•%, .1...: GENERAL AGGREGATE $2,000,000 PRODUCTS-COMPLETED OPERATIONS AGGREGATE $2,000,000 PERSONAL AND ADVERTISING INJURY $1,000,000 ANY ONE PERSON OR ORGANI7ATION EACH OCCURRENCE $1,000,000 DAMAGE TO PREMISES RENTED TO YOU $100,000 ANYONE PREMISES MEDICAL EXPENSE $5,000 ANYONE PERSON !'r4:4..'•'^'.':t:,:.v:<:'i ,:.%:':a'•y;: ,;.!v..<.,?” ?yh•vn\:'<:v...i'n.:•})A y:t. .:v)}':\.:<.vCy...ti�:•.'y<?.:i.sA '?.<.. .,k�. ,1.,. +...°.°ti ;::�::\'��P ,k..,,r•..Jl:>:E''<kati8:'ok r. <%�%;'•R��� .�• w.<.. ,..r'$�') .:1,v _U ::..........:........:..............:...:.,:T....:.'sw•....,.<:sr•:.,::,!•:.,:.y .,..,...,.0......:...}.�.::wti):..,,...:... .,:.? i,�:ikv,,Y,3ik. .�? i.'C?, :::�i'; ..%r�r:.r BODILY INJURY-BODILY INJURY/PROPERTY DAMAGE: Not Applicable PROPERTY DAMAGE ONLY: Not Applicable >:...•,vnv..v.,,v.: 'v•.:nv,..:...::v::..nv::fr:rnv:x. •r:. .v: :::•:::•.v':,...v..:.n•.v.:::r•.H.n.v..: •.:}v. ..atiJ)lC :•??0.: e �'q:y ti ...!• /k;,}'i` �.w <`<'''.'c;}:'):. +yi'%J.:;,y%a>s: .,�:,•r,�,Z': ' !< M1`YT: .ey .s:,>.;E?i�:@'h'':.! k•;.::E3:�? ':.4 .k ^k <,''�h4'k% n,�" L�e: ,'�n:.:S.:•.�:.:x::' },}s:�.��x,!sa...,: r" R,,, t... �_���ii. '�. �,.. .k�r,.s'r`b�y,�•.. i'' h ..rr1 Location 1 14 Cardinal Dr, Carlisle PA 17015 Location 2 Ste 801, 1787 Trindle Rd, Carlisle PA 17015 General Liability Categories: PremisestO erations=P Products/Completed Operations=0 .,.,n`•'•yy�� a#moo..i' : a:!.:x. ,,:;C n.nse 'Y:: !r: J`7i'r•a..,.5..'•s: '"v.�<s.:n}� "�'�,rtv:s'X,'�t;'•/ � .wn...:;o'e. .) k.' rr:..f.:. '•F xF.Y' n.a "':k:.s:t;.y,.}!3¢,n:X.:,f..r :F,�., A,��!Attr.,y1.�::>,:' a 'sC'i r ...;.c.., ,.�%:., f ) : ,o3�gyv�'a k�}• �+.:r... fL'CL�.}:':e;?�' '..`. :{; �%<;'�.b:;',f;.•%�;;;`:g::Si�;`.:: :::�"rF,''�r�Cl�.3,'�.,W; -',f�$, ,.�'�'�iliT ��yT+R� 1 Carpentry 91342 Payroll 127,535 31.497 P $4,017 1 Carpentry 91342 Payroll 127,535 19.9950 $2,550 2 Warehouses-Private-(Ot-Nfp) 68706 Area in Sq.Ft. 1,200 21.667 P $26 2 Warehouses-Private-(Ot-Nfp) 68706 Area in Sq.Ft. 1,200 INCL O INCL - w AU 102(05-91) General Amending Endorsement CG 00 01(12-04) Commercial General Liability Coverage Form CG 2132(05-09) Communicable Disease Exclusion CG 2146(07-98) Abuse or Molestation Exclusion CG 2147(12-07) Employment-Related Practices Exclusion CG 2160(09-98) Exclusion-Year 2000 Computer-Related and Other Electronic Problems CG 24 26(07-04) Amendment Of.Insured Contract Definition CGD 00 67(07-09)Exclusion-Violation of Communications and Information Privacy Lem CGD 0904(09-06) Silver Series Plus General Liability Coverage Enhancement $125 � I President 08/22/11 07:09:46 DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547-0302 PAGE 8 POLICY NUMBER: CPAS063414 :�C:\��<y�y■� ?.�/�•�y t�,;����..�,(����yy��-g9.�!�� �( y!� ;w���!y �y,� :..:•a:.}r:i;}}<:.i:!ark2:ii::;u: �t t�p�■� Endorsement :4! CGD 2010(09-06)Additional Insured-Owners,Lessees or Contractors- $10 Scheduled Person Or Organization CGD 20 33(09-06)Additional Insured-Owners,Lessees,Or Contractors- $250 Automatic Status When Required In Construction Agreement With You CGD 2170(01-08)Cap On Losses From Certified Acts Of Terrorism CGD 2176(01-08) Exclusion of Punitive Damages Related to a Certified Act of Terrorism CGD 21 86(03-06) Exclusion-Exterior Insulation and Finish Systems CGD 24 04(03-00)Waiver of Transfer of Rights of Recovery CGD 90 01 (08-05)Biological And Chemical Contaminants Exclusion CGD 90 33(04-09)Amendments To Policy Definitions CGD 9065(09-06) Total Pollution Exclusion With A Building Heating Equipment Exception c urer7s<}. ''•s%::_.. :.y:.''^::kY�:` :;y.s%ri;",,%'.,.'.? #::''i'C.... ::.,..... .,::: ... n .. ci r.}!,�.. ,.ds' f9!3'-k : r,. ;r.}rE rs3:, ..r. d •�,r.;....,�...,..4k.?k,.;• #iii?y# t r :,(c"'- .sk r'Y i;.: �-ibk:>S'r..t:}..r.,.. tikc,�r'h:: k•:Ev ./a..:-.,:�:R :-X"}. {?:,.dP;;i,r:•.:v.! r it t y $0 u..... <. .�:.:: . .:/ .. ...: •. Y. ...�<�.,,�,.k+.. ''}�.t:y,..;..::?%N•:; .c:k}ua:;. :: <.''.: '"n'�,}>.., .'.!XOi`.:.� •#G:Fr`:Si:`.aid: ut�.`k'..< •: ;c'o:!F'v ..?4 .f•:ia:., -:...::a.y4�.�'<r}..::.:!�!L;..,:.,:1•:::....:�...-:..:- ..'!'�k�+� M-511 F:Y:ri :::.::::w:,::rm::::r:::: .:.. .rr..:.,::...:.:n:.,� ....::.:Z..•.•.::r'i'ii:'F.tl;Yi- ... ::::::.:/..,r:,.,ra:�r,«i%sr.%s:»<»>;��F,,:,,:v%» $7.118 F.: AUDIT FREQUENCY: Annual Commercial General Liability Form,Coverage and Endorsement Supplemental Information ..::•.v:�...�:.. ..:.v.:.:::...:�:::,...... ..::,.c.;......, ..,.: soii::c.,•}. ..,. '-^i,:::,: stir:` •:n:' :a}: �:!......,,K....r:::..;.v:..:r.,J,...C.KIX.•":':-v.. .: :,1.}--rFv..v..:::Y:, -:. i Y. ?44'�S R<� �r�R�'�!'�C2:v:....SfY :4.-.s.. .,�r-.. �.>•ki:5` :�•: �a�:r-.,ry�h: t•t.x; 'd': k..'..ye•, d:t.ii.r,.., %: •: s £ -tAn// C¢fi �k "r bn�� m •¢r w St, t :fl°��,X'a£ ? IT IS HEREBY AGREED&UNDERSTOOD THAT FORM CGD 2010 SHALL READ AS FOLLOWS: ANCOR INC.,SBARRO AMERICA,INC., EKLECCO AND CANADIAN IMPERIAL BANK OF COMMERCE ARE TO BE NAMED AS ADDITIONAL INSURED IN REGARDS TO THE GENERAL LIABILITY,AUTO AND UMBRELLA POLICIES. THIS INSURANCE SHALL BE PRIMARY AND NON-CONTRIBUTING OVER ANY&ALL OTHER COLLECTIBLE INSURANCE OR SELF-INSURANCE. WAIVER OF SUBROGATION APPLIES ON THE GENERAL LIABILITY,AUTO LIABILITY AND WORKERS COMPENSATION POLICIES.ANCOR, INC,SHALL BE NAMED AS CERTIFICATE HOLDER. President 08/22/11 07:09:96 �•o� DONEGAL INSURANCE GROUP MARIETTA,PENNSYLVANIA 17547-0302 PAGE 9 POLICY NUMBER: CPA8063414 i.W;i,:i;.;..F<.: ,}�:�:...;,.,�:^;}::.i.::;i;..::;;:Y,iiii;i.:«:::,:;i;i>:�:.y:.,,: �:.. <..i. ,:;;,:;ii 'ii,..i':. :•«Y }:.> : ,��<�, A,, wR: ... :r..i .}.4vn,,.C;;..,<2}:.: ?.TK:,,. .y,H;,:�}.`$�.. rK.2�.' v.r;iGi\..g^ .;i`�^Ai:23�"-�3::.-;.y;a:�fHY,:.:�n.,.+,:,;.H r:b•.�,cq�Q,.'? ...:.:f:$:,'�`•.Y:;:�Y?`:'y:fa Coverage e of Insurance Page Amendment of General Aggregate Limit of Insurance-Per Project and Included with a Stop Loss 4 Per Location Limitation Broad Form Named Insured Coverage Included in applicable Limit of 3 Insurance Broadened Damage to Premises Rented To You Covers a $300,000 2 Broadened Newly Formed or Acquired Organizations Coverage Included in applicable Limit of 3 180 da Insurance Incidental Malpractice Liability-Nurse,EMT,or Paramedic Coverage Included in applicable Limit of 3 Insurance Knowledge Of An Occurrence,Offense,Claim Or Suit Included in applicable Limit of 4 Insurance Medical Expense increased Limit $10,000 3 Mobile Equipment Redefined Included in applicable Limit of 5 Insurance Non-Owned Watercraft Coverage Included in applicable Limit of 1 Insurance Supplementary Payments-Coverages A and B Bail Bonds Increased Limit $2,000 2 Loss of Earnings Increased Limit $300 per d.ay 2 Unintentional Failure To Disclose Hazards Included in applicable Limit of 5 Insurance f•..:, ,1 ..; .�..:;.. �+ .,!qE:,#:>'O l...'`vrs �•.. � 7^`i:^.`k:^.:�v:.+f'. :E,::.:,,.:,�'}.. -'• .,. ..e .r( �}t }'. f �,.`i.«; `.' $-....i5'..' .. ,�. .�•s:�.... ,s.¢n :^r' ' I --. •�::x x•. ss �:l: '•'-.�. '•..': .���.tu ¢>� .} :y�'a:�{ �1,.ik�',S'3?,�Y'.f' 2':�;'�.{�`,,.��.'�b.,R3` ,'•3:t�:�„X..: yq:.#��`;7;.s.r- .,..` ..X;Y•>wre�:::o;w:i:{ ykf.;,kf5u.r ffi�K .,Y.$^^ / �k.: ,s.t>,� r ird ,;.. .c� Name of Person or Organization:Ancor Inc,831 James St,2nd FI,Syracuse NYµ 13203 Location(s)of Covered Operations:work performed ,.{-ii,:. 'MN„y iY .:1J'IX.y;:A'i�:;:.1:1,i' r'.,t.};uii.. .:.j..: .::q i^ KY^ :vr Yii: :.'h:^:;•i"+'^• :j:: .^��-"• i;>} +,aK. ..:?.y.: ,-.YdQ:.•. .:b'y$,':,•sG:;` SC':%;i: :.c�^:;Y:.??f'>i'r' n../+... #'. 11reii�¢:�.`>."�'!� - Cz 'Q, 'Exr•>^� xvY� :Vii”3i�� ts .f�;s s�,z: t .. •i <:lt�alttdnre .,.-:i:,•. .�. �.:'..:.•�/.::.,.ay»..f,i..i'E:i�...E:;.,:i .t ..r...-.. Name of Person or Organization:AnCor Inc 831 James St Syracuse NY 13203 A�— President 08/22/11 07:09:46 �[,� DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547-0302 PAGE 10 POLICY NUMBER: CPA8063414 Commercial Inland Marine Coverage Part Declarations )ri.►A`�! 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CM 00 01(06-95) Commercial Inland Marine Conditions CMD 90 02(0 8-05) Biological And Chemical Contaminants Exclusion IL 09 35(07-01) Exclusion of Certain Computer-Related Losses ILD 09 52(01-08) Cap On Losses From Certified Acts of Terrorism t `l+ Y�� �°b l � x ::�..:;�: Installation Floater $15 Contractor's Equipment $120 Computer Coverage $250 SA �¢#a#4.#'{..t:aw :r/:`£%. ;'�"'' ';:E<s,:••cA..�3�ass�+::�i%c ':{,.: �t<y�; yi�`i�:''r.-'Y:.;<iF;£:. x»#S:>>x.w:x".'x�.>'>'.�t...;i�,i ;xa'Y�� +:: s�'jCJ»`:'• ., '.;,i{t;.•#i .:i: :i9,•, `k';S:{•: .'� .j'i?'g;y4:. ^s.,< 1 :O %�` '�:: �r���.::�;7:`.<��,�;.x, :<_t;l•:<:..r.�,. �<���,.. .��'��,��..'.�,� �� � 1393 £��:'aM <:.' : 'w i. ,=.,,�c: sb S;kz#,:a:'..,n.'.�;,,N.r ,:!•af;�•,:- ra/ ,.:..:it H%ts.:�;'>;s.#, :�:' x#:;: fs::i� ;, �� President 08/22/11 07:09:96 DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547-0302 PAGE 11 POLICY NUMBER: CPAS063414 :...:.... �w ..::..: �IWM fu FINSTALLATION FLOATER SEE FORM SCHEDULE $15 CMOF 200(05-91) Installation Floater Coverage Form Commercial Inland Marine Form,Coverage and Endorsement Supplemental information NOW '�' .`}"Fi:..- ,r.'t�•u7`i:i>-titt•: �'£•': ..;..::..t.t'�'':,y�.;•i!.,:::';i ...'�. >f$'^?-,<}.3?<>.ii2z?a>;>.,;.f• 3s .b• s>:•;s:;t:ti:;:s';S:;g<;ig3. £%i::.f;#¢'„.•..;;w.£:%•};fug;},rr;::y'".:s,:5c;:. , Installation Of Any One Place Umh Any One Disaster Limit Deductible CARPENTRY $4,000 $4,000 $250 i%§vi.:.;4.. -^:L:x;'A4•. :'w:#.'y�$i� .t{J�',3'>:, ;t#£:#.o>}• `.:E.£•i•;$£,`.`i•.-. .£' yy�+� • .a`.'rkfi ys:^ :.t�f:' .K.�...£�.<:ct}. ty,•% :.R:ZK�'•...:5:... a lif :::::....:f,:•r.3x:.:,:3.-:}?:t: :ri::y.,X,�.tt-..::.r:.:�•r::i�-v- ':>;:: .:;�•�•::Y” }:'. :.i� �Q� President 06/22/11 07:09:46 0(,� DONEGAL INSURANCE GROUP MARIETTA,PENNSYLVANIA 17547-0302 PAGE 12 POLICY NUMBER: CPAB003414 ..55'.' .}\.v;\q:. .:}n:.v..v'}:::^:it{:::2:.;:�}.}:.ti 1. .\\.:. • iri;n,.:.:.::.::. �.p.;....is,:nti.::i�:J'iw�.)i�;Y;}.;.}v;.a:..;}:.i MORE "t.�•'�T^ .�YF.. CONTRACTOR S EQUIPMENT (UNSCHEDULED) $2,000 $250' INCL ANY ONE UNSCHEDULED ITEM $500 LIMIT PER OCCURRENCE TOTAL UNSCHEDULED VALUE CMOF 284(05-91) Contractors Equipment-Unsched.Property Repl:Cost Cov. CMOF 287(05-91) Contractor's Equipment Coverage Form - :':#'; Y"<#S ia'• .z3?c:cx:e --#.. },:L: :Y;:'}.:.}: 3,'. . c:<:%o., ..�#S�:i :x... �:R.;^ �'SE:. :.;ti:s• :s �ii?5%•`.' `�``r`.#r3:.` ik;#:•;" .r.r':::,...�r'.orY.i:•. .,..}_: :'�;:`:.:;n't?✓.>,}.,.;;:r•f;Y•yd:.•..:.:,Y}.:.?..,:yu;:.::::»R:u:�x:.:•:;•>kP �.�:tt? +� ##�� ::�i7i'l{�e. Presldent 08/22/11 0'7:09:46 DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547-0302 PAGE 13 POLICY NUMBER: CPA8063414 sa..: . : ':vE•,.s.;s, .vs.:ax<.sys.\s.,�.;..�.•s:.:.::}.:,.:.:s,+...,���QKF:.E:. ':.';isr:...;:.�o�;w:;f��a��'.sn":y�3.Z<i:., :i:'�i:�.�� ..�,�:C ��sv�,:s,;1 Y�.µ�\. <'R`q. ... ....y;>ifi:\.;?;`:r.`::ox;;>�r,.... � fi;r•.�a:<�:�":F:,.2a�..:k':.:y:\C�,x��,�i�iZ�I�IBFCi.,wzti.z �c Nt COMPUTER SYSTEMS SEE ENDORSEMENT SCHEDULE SEE SCHEDULE COVERAGE $250 ICD 20 01 (01-08) Computer Systems Coverage Form Commercial Inland Marine Form,Coverage and Endorsement Supplemental Information d, K.r:n.,..�:3 f.x:' •':.'c. c?`: ». :`:�'.;S::F „�>x•:F•wF�k yF:,:•;:F..s:;: m: r,.r,.<ii. :K�. •:t y<k •: ,�,��,�„ky�,�Ff<; �s:;,. i;`; ;z;:;,«.: s v>-..:.:� .yrry•��f���;�;s:,�<k s. ..: : ,. ,:. .:.: .7 .f c.ss,:..<:.'x::;.,?f'a;., ,;;4%...•:a..•✓..F�'A:`�ae, k x N s:.£:...k.;i�'2.�s:; Described Premises: AS PER COMMERCIAL PROPERTY COVERAGE PART Limits of Insurance Computer Equipment Data and Media Property at Described Premises $2.000 $2.000 Property In Transit Or Otherwise Away from Described Premises $25 onn Business Income $ All Covered Property Any One Occurrence $ Deductible $500 }:f,:K.j wi,F;oF;3: ..�,.:':xx." .4�:J" #xs•':,.`s. .,•,y"' .. ,;:...., ,:. � ;'s � ar...;�. st. 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CMOF-600(01-08) Policyholder Disclosure Notice Regarding Terrorism Insurance Coverage IL 00 03(04-98) Calculation of Premium IL 0017(11-98) Common Policy Conditions IL 00 21 (04-98) Nuclear Energy Liability Exclusion Endorsement Broad Form IL 0166(01-99) Pennsylvania Changes-Actual Cash Value Endorsement IL 0172(11-93) Pennsylvania Changes IL 02 46 I 0910 01 8010) t PA Notes-PA Insurance Cancell Sllery o r Exem tion L Actt ,. CP 0010(06-95) Building&Personal Property CP 00 30(06-95) Business Income and Extra Expense CP 00 90(0788) Commercial Property Conditions CP 10 30(05-95) Causes of Loss Special Form CPD 90 03(08-05) Biological And Chemical Contaminants Exclusion With Limited Exception For Certain Fire Losses CPD 906(11-00) Silver Series Plus Property Coverage Enhancement IL 09 35(07-01) Exclusion of Certain Computer-Related Losses ILD 09 52 01-08 Ca On Losses From Certified Acts of Terrorism Al f fffSt >::: s' <#:;:<;tip ,::L:h.,. .r< r'•c w?.z:' ALI 102(05-91) General Amending Endorsement CG 00 01 (12-04) Commercial General Liability Coverage Form CG 2132(05-09) Communicable Disease Exclusion CG 2146(07-98) Abuse or Molestation Exclusion CG 2147(12-07) Employment-Related Practices Exclusion CG 2160(09-98) Exclusion-Year 2000 Computer-Related and Other Electronic Problems CG 24 26(07-04) Amendment Of Insured Contract Definition 1 CGD 00 67(07-09) Exclusion-Violation of Communications and Information Privacy Laws CGD 0904(09-06) Silver Series Plus General Liability Coverage Enhancement Endorsement CGD 2010(09-06) Additional Insured-Owners,Lessees or Contractors-Scheduled Person Or Organization 0 CGD 20 33(09-08) Additional Insured-Owners,Lessees,Or Contractors-Automatic Status When Required In Construction Agreement With You I�I CGD 2170(01-08) Cap On Losses From Certified Acts Of Terrorism I CGD 2176(01-08) Exclusion of Punitive Damages Related to a Certified Act of Terrorism CGD 2186(03-05) Exclusion-Exterior Insulation and Finish Systems CGD 24 04(03-00) Waiver of Transfer of Rights of Recovery CGD 90 01 (08-05) Biological And Chemical Contaminants Exclusion CGD 90 33(04-09) Amendments To Policy Definitions CGD 9065 09-08 Total Pollution Exclusion With A Building Heating E ui ment Exce tion CM 00 01 (06-95) Commercial Inland Marine Conditions CMD 90 02(08-05) Biological And Chemical Contaminants Exclusion CMOF 200(05-91) Installation Floater Coverage Form CMOF 267(05-91) Contractor's Equipment Coverage Form CMOF 284(05-91) Contractors Equipment-Unsched.Property Repl.Cost Cov. ICD 20 01 (01-08) Computer Systems Coverage Form President 08/22/11 07:09:46 �(,� DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547-0302 PAGE 15 POLICY NUMBER: CPAS063414 (,►� a �y�y i� •'R45i wpV �� k7,{illSO. � S•:\ `\ti'',:d:,`•:..:.:;:::.:•.::h:....:.:.::�.: .��::::1:..�:).:n•:.� IL 09 35(07-01) Exclusion of Certain Computer-Related Losses ILD 09 52(01-08) Cap On Losses From Certified Acts of Terrorism President 08/22/11 07:09:96 Donegal Insurance Group Marietta,Pennsylvania 17547-0302 POLICY CHANGES COVERAGE IS PROVIDED BY ATLANTIC STATES INSURANCE COMPANY POLICY NUMBER: CPA8063414 POLICY TYPE: Commercial Package Policy This endorsement summarizes changes made to your policy. Please read your:policy, including all Declarations, Schedules, and Endorsements attached to and made part of your policy, carefully for complete information regarding coverage provided. ;:r::� '/;:%';: �y'iff�.3i7�1ir i:i/.� i:l.i .t ,�,.,.:•:.y.rr;'''�iSi:�:;::4;:k..,F.t.;i:`d , ...f.,:fi:G:v': n...«.: •'.!S:r.-:::tea::.: .•{r .:f'fi+ :./:: ,}+t,. Y,«:::.:««:r:,>'eo ::!...;;r ::,.<::::,.:.,:n:y'r ., ,.'+,r'.i5? ... C!+•..,.,rr ".'/. rr..;.;..: '%F:I,3.:r.. t+•!//,:'./. .:^..w:.4.. ........., ... v.:.... f.......:::........+ ^....:.:,.. ^.r.,,,:.:n./'!.':.:::iii';':. '». ... •:}.s::..i:rs%ii:�%<"^�i:..ny/:�i'""ii fiiii� v.fl`f'.:'f.+ii i..u. %:::;:, .../e., .......: ...: .:....:.r. s..i? +............�:.,,.../ ..::,.,..:.!::.. , ....,... ...i:�:::�..�:••s..."-s' ./:::t:�r.::::,rf.s:yY..�:::::: :/.....�� ..-0'.Sr' ::r:.!';•r`4YS >:xnYYC%:•f:'f. •S:nie ::/. :d7/« r,:ar'•: :�" s:u!% i. 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Added form:ICI)70 01(03-10)Builders Risk Coverage Form Added form:IL 09 35(07-01) Exclusion of Certain Computer-Related Losses Added form:ILD 0952(01-08) Cap On Losses From Certified Acts of Terrorism Added Location:a 1031 Ne Mlle Rd, Carlisle PA 17013 Full Term Premium (including this transaction): $18,580 PREMIUM CHANGE: Premium Effect of this transaction: $1,203 �Q���7� • / /J President 12/20/11 11:16:27 Dpi 1Y (� DONEGAL INSURANCE GROUP MARIETTA, PENNSYLVANIA 17547-0302 PAGE 3 POLICY NUMBER: CPA8063414 Commercial Inland Marine Coverage Part Declarations t.. ,.,•;:».•::...,,rc...;:,,.::>??:,,?,:rr..,t.yy.:.#',n:a:4...:r. .::4�:Y,.: .y., ia:; 'y'c.. E'3;cs?.` :Yr< d: ,...... ...,.....::..4:t•:4;...:.r..,i..:::::..:s.:.......c.,,F.:..,,.::;:,:..,.,r ..a:. :.fi:.` •��<�;. ^:s's,•: %:•r.� .i �,�,,��Fi�........ ..........:...,......,, .. ::.v:.::,.:.:......!:.::.T...... t:Y,,.. : ... f•:.:vi:a:?:;i:t•..:.. n. fi�: INSTALLATION FLOATER SEE FORM SCHEDULE $15 ." ? 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CMOF 267(05-91) Contractor's Equipment Coverage Form .,..-..os3:i ;:a i„�:;.^��r•:r?: ; • '>"R}:.•• ""\i;. 8z fi.:.11 ` 'Z`i President 12/20/11 11:16:27 DONEGAL INSURANCE GROUP MARIETTA,PENNSYLVANIA 17547-0302 PAGE 5 POLICY NUMBER: CPAS063414 ,,��yy���� \ v� \iL:ih�a.tti}:vv':'+� -k } ] v:•ti>}C{}� {� ;�{� �c�j�}`,y� .'G73".r.,::' ,..•A3.4 ..,�� � .;'{ '}t}+:;2<> rk,>,s' ..a..::}..:}: }�;;;`:»:YT _I�l `:T:! _ .`5::"v.<,f:a:': .'GlYltil4�1} k: SEE ENDORSEMENT SCHEDULE COMPUTER SYSTEMS DULE SEE SCHEDULE COVERAGE $250 }:gJkT.'i I I 14'.�:�.' i7"Siil. 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LOCATION: B BUILDING: 1 1031 Newville Rd, Carlisle PA 17013 LIMIT OF INSURANCE $560,000 ADDITIONAL COVERAGES BUILDING MATERIALS AND SUPPLIES OF OTHERS $5,000 LAWNS,TREES,SHRUBS AND PLANTS $250 for any one tree,shrub or plant $1,000 EACH OCCURRENCE DEDUCTIBLE: $500 TOTAL PREMIUM AT THIS LOCATION: $1,818 ,�' ":Y::. ��;, '•j:. Y.:':r^:^C,S:v]}v:•�:kK':' nYii"''� .,f�3' t� {. Y � ::...:...::.... � z r}.�`, ,33si .,(.art�i.�:�. .{:'�.,:.�A••.:f•,r :2..{e ",o°:.a Y+y :;;.� ADDITIONAL COVERAGE LIMIT OF INSURANCE BUILDING MATERIALS AND SUPPLIES AWAY FROM A"JOB SITE" $10,000 PERSONAL PROPERTY $5,000 TESTING $5,000 President 12/20/11 11:16:27 : �o ..:� ...: :. _�. e,� :<€%>f {{(�?:rY£: :.lrl'.5'3t1;� ':P #Esi" ,.r� PttQ,��Y I?lit�tli::9"la a:t3'r3�3.o: .:: .. •.. , , . .. . i . .. . :: ---COMMERCIAL:LIABILITY UMBRELLA':P;OLICY ;: ...:%. . . . ....: :.:.:::' ...},.; .. .. : .:.: ..: . .. .....:.. . ICOVEfRAG.E.fS PROUl QE08Yz DONEAL111UTilALaNBURANCE:`COMPAN? >:. .. 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'ra .,#{" •4'kl,r') xS.y {d:fo^.ys'{ '^:f" {:.�:{;,'+y`'x':: �..:n ,x�':•7.a?,..;,kkX.'k, :.....xs:,..... .. :�:.::k;.h.N:i utt:k CMOF 600(01-08) Important Notice To Policyholders-Policyholder Disclosure Notice Regarding Terrorism Insurance Coverage CU 00 01 (12-01) Commercial Liability Umbrella Coverage Form CU 00 02(12-02) War Liability Exclusion CU 0131(09-00) Pennsylvania Changes CU 2112(09-00) Abuse or Molestation Exclusion CU 21 18(09-00) Excl-Year 2000 Computer-Related&Other Electronic Prob. 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ORMIOF'INSURED.S:.BUSINESS:: :: DONEGAL INSURANCE GROUP Workers Compensation MARIETTA,PENNSYLVANIA 17547-0302 _ POLICY NUMBER: WC 8063414 EXTENSION OF INFORMATION PACE CLASSIFICATION OF OPERATIONS STATE:PA LOC.1 1787 Trindle Rd Ste 801 Carlisle PA 17015 Code No. Classifications Description Premium Basis Rate Per Estimated Estimated Total $100 of Total Annual Remuneration Annual Remuneration Premium 652 Carpentry If Any 14.24 $0 953 Clerical Office Employees NOC 1,360 .38 $5 651 Carpentry-Commercial Structures 111,935 .11.19 $12,526 ESTIMATED TOTAL ANNUAL PREMIUM FOR THIS LOCATION $12,531 9807 PART TWO-EMPLOYERS LIABILITY INCREASED LIMITS $238 0930 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS $100 9698 EXPERIENCE RATING PLAN MODIFICATION-FINAL .85 $1,930 9887 SCHEDULE RATING PLAN MODIFICATION .90 $1,094 0083 PREMIUM DISCOUNT -$543 9740 TERRORISM .03 $34 9741 CATASTROPHE(OTHER THAN CERTIFIED ACTS OF TERRORISM) .02 $23 ESTIMATED TOTAL ANNUAL PREMIUM FOR STATE:PA $9,359 FORMS AND ENDORSEMENTS CONTAINED IN THIS POLICY WC 000421C 09-08 Catastrophe(Other than Certified Acts of Terrorism)Premium Endorsement 1 WC 000422A 09-08 Terrorism Risk Insurance Program Reauthorization Act Disclosure CMOF 612 10-10 PA Construction Classification Premium Credit Application I WC 0000008 7-11 Workers Comp.and Employers Llab.Ins.Policy I WC 000313 04-84 Waiver of Our Right to Recover From Others Endorsement i WC 000406 4-84 Premium Discount Endorsement t( I WC 000419 01-01 Premium Due Date Endorsement I WC 370310C 12-09 Excl.of Executive Officers Endt-PA I WC 370402 01-91 Pennsylvania Const Class.Prem Adj Endt 1 WC 370405 8-96 Pennsylvania Merit Rating Plan Endt. EI WC 370601 4-84 Special Pennsylvania Endt-Insp.of Manuals i WC 370602 4-84 Pennsylvania Notice 'I WC 370603A 8-95 PA Act 861986 Endt-NonRen Notice of Premium Change residant 08/16/11 07:02:16 04+ TL t f 'DOAMAL 1NSIIRANCE GROUP MARIETTA;PENNSYLVANIA 17547-0302 GENERAL LIABILITY LU-127A PREMIUM AUDiTADJUSTMmir Ed.1109 COVI=RAGE IS PROVIDED BY ATLANTIC STATES INSURANCE COMPANY The estimated premium on the policy is hereby adjusted in accordance with the audit for the period indicated. POLICY PERIOD FROM:10/012010 TO: 10/012011 DESCRIPTION CLASS ESTIMATED ACTUAL EXPOSURE - i PREMIUM CODE EXPOSURE EXPOSURE DIFFERENCE Premises Completed OpslOther Operations Pennsylvania Location: 1 CARPENTRY 91342 $127,535 $300,335 $172,800 $5,444 $3,455 Terrorism Coverage Premium $178' TOTAL EARNED PREMIUM $9.077 TOTAL BALANCE DUE INSURED Q COMPANY $9,077 Additional Premiums due Company are payable upornrecelpt of this premium adjustment endorsement. Return Premiums due Insured are payable.provided the Estimated Deposit Premiums are paid in full: This premium adjustment is for the policy period Indicated and forms a part of Policy Number: CPA8063414 Issued to: Hughes Contracting Inc Adj.Computed at Marietta pA Date: Agent R T Dunn Incuranee Inc-0nnW7 a :EX D J • Q I ` J J Q DONEGAL COMPANIES — Policyµvumber CPA 8063414.11 Policy Name COMMERCIAL PACKAGE Company Name Hughes Contracting Inc Contact's Name Seth/Jennife Hughes FEDERAL ID. 26-1520160 Street Address 1787 Trindle Rd City Carlisle State PA AUDIT SUMMARY Zip 1 015 Policy Date. 10//01/2010 To 10/0112011 BATCH NUMBER INFACS CODE INVOICE NUMBER INS Code Reporting Date 10/01/2010 To 10/01/2011 4-12103-1 E 1 111439 2719 201 Completion Date 11/0212011 Phone 385-0639 L#STATE LOCATION CODE CLASS TOTAL ADJUSTED PREVIOUS DELTA TOTAL BASIS 1 PA. Carlisle 91342 Carpentry 347,056.00 300,335.00 127,535 135.49° SPLIT 1 TOTAL SPLIT 2 TOTAL AUDIT TOTAL ADJUSTED TOTAL TOTAL BASIS TOTAL DELTA 0.00 0.00 1 =347,DS6.001 300,335A0 1 127,535 135.49% Description of Operations THIS IS A CORPORATION THAT SPECIALIZES IN RESTAURANT CONSTRUCTION,AND SOME RESIDENTIAL CONSTRUCTION REMODELING AND REPAIRS.TIME FOR THE JOBS ARE NOT SEPARATED BETWEEN RESIDENTIAL AND COMMERCIAL. BOTH OFFICERS ARE EXCLUDED FROM PAYROLL. (!!t7nrs Hans Office,11 Pgjill Drive,Marietta,Pennsylvania 17457 (717)426-1904) THIS AUDIT REPORT IS MADE FROM INTERVIEW(S)AND OBSERVATIDN(S)WITH INSURED OR THEIR REPRESENTATIVES.INFACS IS NOT AN INSURER AND DOES NOT GUARANTEE THE ANSWERS TO THE QUESTIONS AND)oR NARRATIVE REMARKS CONTAINED IN THIS REPORT.THIS REPORT OUTLINES SUCH CONDITIONS AS WERE OBSERVED AND CONSIDERED AT THE TIME OF CALL AND IS NOT INTENDED TO INDICATE THAT THERE ARE NO OTHER POSSIBLE EXPOSURES.THIS AUDIT REPORT CONTAINS INFORMATION FOR FINAL BILLING AND UNDERWRITING PURPOSES ONLY AND IS TO BE USED FOR NO OTHER PURPOSE..WEIDO NOT ASSUME LEGAL LIABILITY FOR REPORTS DELAYED FOR ANY CAUSE.THE REQUESTING COMPANY AND ITS REINSURERS ADREE TO THE FORGOING CONDITIONS AND FURTHER AGREE TO HOLD INFACS AND ITS REPRESENTATIVES FREE AND HARMLESS FROM ANY CLAIMS AND LIABILITIES,INCLUDING LEGAL FEES.THIS REPORT MUST BE HELD IN CONFIDENCE. DONEGAL COMPANIES Policy Number CPA 8063414.11 Policy Name COMMERCIAL PACKAGE Company Name Hughes Contracting Inc FEDERAL ID. 26-1520160 street Address 1787 Trfndle Rd city Carlisle State PA zip 17015 SUMMARY DETAIL Policy Date 10/01/2010 To 10/01/2011 Reporting Date 10/01/2010 To 10101/2011 BATCH NUMBER INFACS CODE INVOICE NUMBER INS Codc Auditor 201 4-12/03-1 aE 111439 2719 4 Completion Date 11/02/2011 Phone 385.0639 N# L# Code Title Name/Group Total Adjusted Description Function 1 1 91342 President Seth Hughes 21,120.00 15,600.00 COMMERCIAL CARPENTRY Officer 2 1 91342 Carpentry Staff(6-7) 284,735.00 284,735.00 COMMERCIAL CARPENTRY Employee 3 1 91342 Clerical 8 Sales 41,201.00 0.00 CLEERICAL&SALES Clerical Source of Data Verification Was There INSURED � 1 941 Period Totals UC-2 10/01/2010 To 10/01/2011 347,056 Le al Entity ubcontractor Amount Gross Overtime To Corporation F $p To To (!t nfacs To Ne ne Office, II PAIILL.DRIVE,MARIETTA,PBNA'SYLI'ANIA 17547 (717)420-1904 To TOTAL 347,056 D� WAL 1NSURANCE`GROIIP MARIET'T'A,PENNSYLVANIA 17547-0302 WORKERS COMPENSATION LU-182 PREMIUM AUDIT ADJUSTMENT Ed.1109 COVERAGE IS PROVIDED BY DONEGAL MUTUAL INSURANCE COMPANY The estimated premium on the policy is hereby adjusted in accordance with the audit for the period indicated. POLICY PERIOD FROM: 101012010 TO: 10/012011 DESCRIPTION CLASS EFFECTIVE ESTIMATED ACTUAL RATE EARNED CODE DATE PAYROLL PAYROLL PER$100 PREMIUM Pennsylvania Carpentry-Commercial Structures 651 10/01110 $111,935 $284,735 10.63 $30,267 Carpentry 652 10/01/10 $0 $0 13.15 $0 Salespersons-Outside 951 10/01/10 $0 $11,680 .74 $86 Clerical Office Employees NOC 953 10/01/10 $1,360 $19,395 .40 $78 Part Two-Employers Liability 9807 $578 Increased Limits - Waiver Of Our Right To Recover From 0930 .02 $609 Others Experience Rating Plan Modification- 9898 .854 -$4,816 FINAL Schedule Rating Plan Modification 9887 .90 -$2,700 Premium Discount 0063 -$2,919 Terrorism 9740 .03 $95 Catastrophe(other than certified acts 9741 .02 $63 of terrorism) Expense Constant 0900 $140 Employer Assessment(0.0207) 0938 $465 EARNED PREMIUM S22,946 LESS DEPOSIT PREMIUM TOTAL BALANCE DUE F-� INSURED a COMPANY $13,550 Additional Premiums due Company are payable upon receipt of this premium adjustment endorsement Return Premiums due Insured are payable provided the Estimated Deposit Premiums are paid in full. This premium adjustment is for the policy period indicated and forms a part of Policy Number: WC 8063414 Issued to: Hughes C--t^^tin^Inr Adj.Computed at m,rieft,Ps Date: 11 r2211 1 Agent DONEGAL COMPANIES Policy NumbevWC 8063414.11 Policy Name WORKERS COMPENSATION Company Name Hughes Contracting Inc Contact's Name Seth/Jennite Hughes FEDERAL ID. 26-1520160 Street Address 1787 Trindle Rd City Carlisle state PA Zip 17015 AUDIT SUMMARY Policy Date 1010112010 To 10/01/2011 . BATCH NUMBER INFACS CODE INVOICE NUMBER INS Code Reporting Date 1 0/0 11201 0 To 10/01/2011 4_.1,2/03-17 E 1 111440 1 2719 G 4 t Auditor 201 Completion Date 11/02/2011 Phone 385-0639 L#STATE LOCATION CODE CLASS TOTAL ADJUSTED PREVIOUS DELTA TOTAL BASIS 1 PA Carlisle 652 Carpentry Residential 0.00 0,00 0 1 PA Carlisle 953 Clerical Office Employee 29,521.00 19,385.00 1,360 1325.370 1 PA Carlisle 651 Commercial Carpentry 305,855.00 284,735.00 111,935 154,38° 1 PA Carlisle 951 Outside Salesmen 11,680.00 11,680.00 0 SPLIT 1 TOTAL SPLIT 2 TOTAL AUDIT TOTAL ADJUSTED TOTAL TOTAL BASIS TOTAL DELTA 0.00 Q.00 347i05$00 315r$0000 11,,29§� 178.74%1 I L-^- Description of Operations --J THIS IS A CORPORATION THAT SPECIALIZES IN RESTAURANT CONSTRUCTION,AND SOME RESIDENTIAL CONSTRUCTION REMODELING AND REPAIRS.TIME FOR THE JOBS ARE NOT SEPARATED BETWEEN RESIDENTIAL AND COMMERCIAL. BOTH OFFICERS ARE EXCLUDED FROM PAYROLL. 7na(c s imme pyrite,I Pajill Drive,Marietta,Pelulsylvania 17457 (717)426-1904) THIS AUDIT REPORT IS MADE FROM INTERVIEWS!AND OBSERVATION(S)WITH INSURED OR THEIR REPRESENTATIVES.INFACS TS NOT AN INSURER AND DOES NOT GUARANTEE THE ANSWERS TO THE OUESTIONS AND)OR NARRATIVE REMARKS CONTAINED IN THIS REPORT.THIS REPORT OUTLINES SUCH CONDITIONS AS WERE OBSERVED AND CONSIDERED AT THE TIME OF CALL AND IS NOT INTENDED TO INDICATE THAT THERE ARE NO OTHER POSSIBLE EXPOSURES,THIS AUDIT REPORT CONTAINS INFORMATION FOR FINAL BILLING AND UNDERWRITING PURPOSES ONLY AND IS TO BE USED FOR NO OTHER PURPOSE.WE DO NOT ASSUME LEGAL LIABILITY FOR REPORTS DELAYED FOR ANY CAUSE.THE REQUESTING COMPANY AND RS RE4NSURERS AGREE TO THE FORGOING CONDITIONS AND FURTHER AGREE TO HOLD WFACS AND ITS REPRESENTATIVES FREE AND HARMLESS FROM ANY CLAIMS AND LIABILITIES,INCLUDING LEGAL FEES.THIS REPORT MUST BE HELD IN CONFIDENCE. DONEGAL COMPANIES Policy Number= 8063414.11 Policy Name WORKERS COMPENSATION Company Name Hughes Contracting Inc Street Address 1787 Trindle Rd FEDERAL 1D. 26-1520160 city Carlisle State PA Zip 17015 SUMMARY DETAIL Policy Date 10101/2010 To 10/01/2011 Reporting Date 10/01/2010 To 10/01/2011 BATCH NUMBER INFACS CODE INVOICE NUMBER INS Cod* Auditor 201 412/03-1 E 111440 2719 —F—74-� Completion Date 11/0212011 Phone 385-0639 !N#L# Code Title Name/Group Total Adjusted Description Function 6 1 652 None 0.00 010C NO ACTIVITY Employee 2 1 953 Secretary Jennifer Hughes 10,136.00 0.0( OFFICE MANAGEMENT Exclusion 3 1 953 Amanda Botelho 19,385.00 19,385.0 C CLERICAL OFFICE Employee 2 1 651 President Seth Hughes 21,120.00 0.0C CARPENTRY COMMERCIAL Exclusion 5 1 651 Carpentry Staff (6-7) 284,735.00 284,735-0 C COMMERCIAL CARPENTRY Employee 4 1 961 George Gentile Jr 11.680.00 11,680.0( ESTIMATING Employee Source of Data Verification Was There - INSURED 1 1941 Period Totals JUC-2 10/0112010 To 1213IM10 91,549 Legal Entity Subcontractor Amount Gross Overtime 01/01/2011 To 03131/201 82,395 Corporation F $01 1 04/01/2011 To 06130/201 76,9$3 07/0112011 To 09/30/201 96,179 (!t7nfa1`c- S TO Hame Office, 11 PAJfLL DRIVE,MARIETTA,PENNSYLVANIA 17547 (717)426-1904 To I TOTAL 347,056 DONEGAL MUTUAL INSURANCE COMPANY WORKERS COMPENSATION LU-182 AUDIT INVOICE 3/91 The estimated premium on the policy is hereby adjusted in accord with the audit for the period indicated. POLICY PERIOD FROM 10/01/11 TO 03/20/12 CANC DATE UNITS PREMIUM DESCRIPTION CODE EFFECTIVE RATE PAYROLL EARNED ASSUMED CARPENTRY-DETACHED ONE OR 652 14..24 NONE $ 0 TWO FAMILY DWELLING CLERICAL NOC 953 .38 $ 635 2 CARPENTRY-NOC 651 11.19 52,274 5,849 WAIVER OF SUBROGATION 0930 47 INCREASED LIAB COV II 9807 1.9% 111 EXPERIENCE MOD 9898 .85 - 901 SCHEDULE MOD 9887 .90 - 511 EXPENSE CONSTANT 0900 65 TERRORISM 9740 .03 - 16 CATASTROPHE 9741 .02 11 EMPLOYER ASSESSMENT 0938 .0188 88 EARNED PREMIUM $4,777 LESS DEPOSIT PREMIUM $9,678 TOTAL BALANCE DUE: �]X INSURED F-1 COMPANY $ 4, 901 Additional Premiums due Company are payable upon receipt of this premium adjustment endorsement. Return Premiums due Insured are payable provided the Estimated Deposit Premiums are paid in full. This premium adjustment is for the policy period indicated and forms a part of Policy Number WC 8063414 0 4 issued to: HUGHES CONTRACTING INC Adj.computedat Marietta, PA Date 07/11/12 Agent R T DUNN INSURANCE INC (AUTHORIZED REPRESENTATIVE) 4 � STATEMENT OF ACCOUNT September 24,2012 Hughes Contracting,Inc. Suite B01 1787 Trindle Road Carlisle, PA 17015-9728 ACCOUNT NUMBER: AB 1013460 Premlum CA 8063414-03(10/01/11 to 03125/12) 3,415.00 Cancellation Credit (1,774.00) CPA 8063414-02(10/01/10 to 10/01/11) Audit 9,077.00 CPA 8063414-03(10/01/11 to 03/25112) 7,853.00 Endorsement 9,077.00 Endorsement 1,203.00 Cancellation Credit (9,644.00) CXL 8063414-04(10101/11 to 03125/12) 2,035,00 Cancellation Credit (1,056.00) WC 8063414-03(10/01/10 to 10/01/11) Audit 13,550.00 WC 8063414-04(10101/11 to 03120/12) 9,678.00 Audit Credit (4,901.00) Service/Late Charges 108.00 Total Due: 38,621.00 Payment€ (3,896.00) 10/21/11 200.00 10/24/11 to audit 10/01/09 to 10/01/10 term (3,248.00) 11/29/11 (5-964 001 01/19/12 Total Paid: 211 80 06 0 TOTAL DUE DONEGAL MUTUAL INS CO 25,713.00. Q EXHIBIT a W J w FQ- J J Q COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW DONEGAL MUTUAL INSURANCE COMPANY and ATLANTIC STATES INSURANCE COMPANY I Plaintiffs No. IS lu( vs. HUGHES CONTRACTING, INC. CIVIL ACTION c. Defendant ' . M Dc) � ENTRY OF APPEARANCE ? C Kindly enter my appearance on behalf of Plaintiffs, DONEGAL MUTUAL INSUTIAIC3"t E COMPANY and ATLANTIC STATES INSURANCE COMPANY,in the above-captioned matter. AMATO AND LESSA, P.C. By: � 9 1! 0 Michael R. Lessa, Esq., Atty ID #88617 David A. Lovejoy, Esq., Atty ID #19829 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Paul F. Troisi, Esq., Atty ID#309511 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866-0400 A DEBT COLLECTION LAW FIRM Dated: March 5, 2013 SHERIFF'S OFFICE OF CUMBERLAND COUNTY Ronny RAnderson ILED-OFFi L Sheriff (IF THE PROTHONOTAr, Jody S Smith Chief Deputy 2013MAY30 Q Richard W Stewart I}MELN{ COUNTY Solicitor OFFJ,E FT"ESR�PI F PENNSYLVANIA Donegal Mutal Insurance Company Case Number vs. Hughes Contracting, Inc. 2013-2757 SHERIFF'S RETURN OF SERVICE 05/23/2013 05:49 PM- Deputy Noah Cline, being duly sworn according to law, served the requested Complaint& Notice by handing a true copy to a person representing themselves to be Seth Hughes, Owner,who accepted as"Adult Person in Charge"for Hughes Contracting, Inc. at 14 Cardinal Drive, South Middleton Township, Carlisle, PA 17015. NOAH CLINE, DEPUTY SHERIFF COST: $34.78 SO ANSWERS, May 24, 2013 RbNW R ANDERSON, SHERIFF (c)CountySuite Sheriff,Tefeosatt,Inc. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW • DONEGAL MUTUAL INSURANCE . • COMPANY and ATLANTIC STATES . • INSURANCE COMPANY . Plaintiff : No. 13-2757 Civil c-) N -1 W C- '1 • HUGHES CONTRACTING, INC. 7_ CIVIL ACTION ..<x' - t�=', r---"z --t Ca -: -, • Defendant Z>� `i i:1";5 PRAECIPE FOR JUDGMENT __, c) TO THE PROTHONOTARY, CUMBERLAND COUNTY: Kindly enter judgment by default for want of an answer in favor of Plaintiff and against the above-named defendant(s) only and assess damages as follows: Debt $26,397.74 Interest (from March 5, 2013 to June 26, 2013 at 6% per annum) $461 .97 Costs $155.03 Total $27,014.74 I CERTIFY THAT THE FOREGOING ASSESSMENT OF DAMAGES IS FOR SPECIFIED AMOUNTS ALLEGED TO BE DUE IN THE COMPLAINT AND IS CALCULABLE AS A SUM CERTAIN FROM THE COMPLAINT. Pursuant to RCP 237.1 , I certify that a copy of the annexed written notice(s) of intention to file this praecipe was mailed or delivered to all parties against whom judgment is to be entered and to their attorney of record, if any, after the default occurred, and at least ten days prior to the date of filing of this praecipe. Please note that said notice was mailed to all parties on June 13, 2013. Dated: June 26, 2013 4,I(0.5o Pp Arri AMATO AND LESSA, P.C. 33774 By: - aR �9.9 No+rCQIu iied ichael R. Lessa, Esq., Atty ID #88617 David A. Lovejoy, Esq., Atty ID #19829 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Paul F. Troisi, Esq., Atty ID #309511 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866-0400 A DEBT COLLECTION LAW FIRM 2130042 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW • DONEGAL MUTUAL INSURANCE . • COMPANY and ATLANTIC STATES • • INSURANCE COMPANY . • Plaintiff : No. 13-2757 Civil • vs. . • • HUGHES CONTRACTING, INC. . : CIVIL ACTION • • Defendant . CERTIFICATION OF ADDRESSES I do certify that the precise last known address of the within named plaintiff is: 1 195 River Road, Box 302 Marietta PA 17547-0302 I do certify that the precise last known address of the within named defendant is: 14 Cardinal Drive Carlisle PA 17015 AMATO AND LESSA, P.C. By: Michael R. Lessa, Esq., Atty ID #88617 David A. Lovejoy, Esq., Atty ID #19829 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Paul F. Troisi, Esq., Atty ID #309511 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866-0400 A DEBT COLLECTION LAW FIRM COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW • DONEGAL MUTUAL INSURANCE . • COMPANY and ATLANTIC STATES . • INSURANCE COMPANY • Plaintiff : No. 13-2757 Civil vs. • HUGHES CONTRACTING, INC. • • Defendant TO: Hughes Contracting, Inc. 14 Cardinal Drive Carlisle PA 17015 Date of Notice: June 13, 2013 IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 AMATO AND LESSA, P.C. By: ll Michael R. Lessa, Esq., Atty ID #88617 David A. Lovejoy, Esq., Atty ID #19829 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Paul F. Troisi, Esq., Atty ID #309511 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866-0400 A DEBT COLLECTION LAW FIRM Attorney File# 2130042 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW • DONEGAL MUTUAL INSURANCE • COMPANY and ATLANTIC STATES • INSURANCE COMPANY • Plaintiff : No. 13-2757 Civil • vs. • • HUGHES CONTRACTING, INC. : CIVIL ACTION • • • Defendant NOTICE OF JUDGMENT (XX) NOTICE IS HEREBY GIVEN THAT A JUDGMENT IN THE ABOVE CAPTIONED MATTER HAS BEEN ENTERED AGAINST THE ABOVE-NAMED DEFENDANT(s) IN THE AMOUNT OF $27,014.74 ON July L , 2013. ( ► A COPY OF ALL DOCUMENTS FILED WITH THE PROTHONOT RY 0 CUMBERLAND COUNTY IN SUPPORT OF THE WITHIN JUDGMENT IS/ARE ENCLOSED. PROTHONOTARY - CUMBER Ce If you have any questions concerning the above, please contact the undersigned. AMATO AND LESSA, P.C. By: Michael R. Lessa, Esq., Atty ID #88617 David A. Lovejoy, Esq., Atty ID #19829 Justin N. Davis, Esq., Atty ID #84464 Daniel A. Wechsler, Esq., Atty ID #203922 Paul F. Troisi, Esq., Atty ID #309511 Attorneys for Plaintiff 107 North Commerce Way Bethlehem, PA 18017 (610) 866-0400 A DEBT COLLECTION LAW FIRM