271-22 Attachment-SUBMISSION.pdf

Dear Business Representative, Thank you for your recent filing with the State of New Jersey. Following is a confirmation of your fee payment, please print a copy for your records. Payment Type: Credit card transaction charge on 5/20/2022 9:39:30 PM Submission [D: 127139 Payment Transaction !D: 232866 i Effective Date: 05/20/2022 Paid Amount: $150.00 Convenience Fee: $3.50 Total Paid Amount: $153.50 Confirmation Number: e13fa5e7-aded-442b-8317-35e985ac5427 Form Name: Initial AA302 Form Description: Empioyee Information Report (AA302 Initial) Please allow at least one (1) business day for your payment to post to your account.

i , : - i Main Menu ielp ‘Translate this Page )) Sete! Language | ¥ Translation Digcta i View Employee Information Report (AA302 Initial Form) Section A - Company Identification \ ' £4, FID Number or SSN: 146784792 2, Type of Business: ‘SERVICE | 3, Total NO. Employees in the Entire Company: ' 1 } 4. Company Name: ED Arborists Foresters i i t i 5, Street: 976 Old School House Road City: ‘Blairstown “County: SUSSEX i ' State: .NU ~ "Zip Code: ,07825 6, Name of Parent or Affiliated Company (if none, so indicate): i 5 city: ‘State: | | Zip Code: | : ) 7, Company Type: ' Single-Establishmen 8. State the Number of Establishements in NJ location: 0 i i 9. Total Number of employees at establishment which has been awarded the contract: 4 : | 40. Public Agency Awarding Contract: Monmouth County Parks ‘City: ‘Lincroft | County: MONMOUTH State: (NJ Zip Code: 07738 | i Section B - Employment Data 14, Report all permanent, temporary and part-time employees ON YOUR OWN PAYROLL. Enter the appropriate figures on all lines and in all columns. | Where there are no employees in a particular category, enter a zero. Include ALL employees, not just those in minority/non-minority categories. vio Ceteragies |Officals / Managers Professionals j Technicians | ' Sales Workers Office & Clerical Craftworkers (Skilled) Operatives (Semi-skilled) Laborers (Unskilled) , |Service Workers. Temporary & Part-Time Employees TOTAL. 0 vy) a Q 0 0 0 cu 9 ie} Q TOTAL MALE GOUNT: 1 i FEMALE dak: Gaicvagios Officals / Managers :Professionals Technicians Sales Workers Office & Clerical Craftworkers (Skilled) Operatives (Semi-skilled) Laborers (Unskilled) Service Workers : Temporary & Part-Time Employees TOTAL oe seeaeecooce 0 i) oO oO i) i) o o o 0 o TOTAL FEMALE COUNT: 0 L __ 12. How Was Information as to Race or Ethnic Group in Section B Obtained: ‘Other ; ‘18. Date of Payrall Period Used From: (5/2/2022 To: 5/9/2022 Section C - Personal Identification 14, Contact Name: ‘Evan Diltuvio 15. Tite: sOwner 46, Contact Email: ‘dilluvioevan@gmail.com j

" EVANDIL-O1 —___MCRUZ ACORD CERTIFICATE OF LIABILITY INSURANCE e022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy{ies) must 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). PRODUCER — House - RPM RPM Insurance Agency RPM Insurance Agel NE 201 Edward curry Ave. No, Ex [BR Suite 202 Fives: none@acrisure.com Staten Ietand, NY 10314 INSURERS) AFFORDING COVERAGE NAIC # mwsurer a; Hartford Underwriters Insurance Company [30404 INSURED nsurer a: Sentinel Insurance Company, Ltd 11000, Evan Dilluvio Tree Consulting imsurerc : Lloyd's 1524210, 976 Old School House Rd. INSURER D: Blairstown, NJ 07825 INSURER E: INSURER Fs 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 PERtOD 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. Nie “TYPE OF INSURANCE aot GBR POLICY NUMBER COREE | CORONER chars A |X | conmerciat GENERAL ABILITY EACH OCCURRENCE $ 7,000,001 7 ccamstae [%] occur hoseMast ave erv2o22 | or2023 | RRMARETG ENTE ca Is 7,000,001 |_| MED EXP (Any one person) | § 5,001 | PERSONAL & ADV INJURY | 9. 7000,001 | GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE I$ 2,000,001 | X | pouicy {| SBS Loc PRODUCTS - COMP/OP AGG | $ 1,000,001 OTHER: 8 | AUTOMOBILE LIABILITY GQMERESSINGLELIMIT Tg |__| any auto BODILY INJURY (Par person)_| $ [| Re Pony sae BODILY INJURY (Per acxidert| $ || RUF ony ROTES UND et dala

COMP/OP AGG | $ 1,000,001 OTHER: 8 | AUTOMOBILE LIABILITY GQMERESSINGLELIMIT Tg |__| any auto BODILY INJURY (Par person)_| $ [| Re Pony sae BODILY INJURY (Per acxidert| $ || RUF ony ROTES UND et dala A ‘ |_| umoneacas | [occur EACH OCCURRENCE $ EXCESS LiAB CLAIMS: MADE ‘ABGREGATE ‘ 5 peo | [aerenrions “ 3 WORKERS COMPENSATION X [eiinne |_18" ome wal POWECASTAWH ervaozz | 67/2023 |e: excuacemenr |e p00 NN E.L, DISEASE - EA EMPLOYEE! $ 000,001 —4 SeSERTON OF SpeRATIONS below Ex, DISEASE -FouCY amir | ¢ 7,000,00¢ C {Professional Liabilt IANES 131222 6/1/2022 | 6/1/2023 [Aggregate 7,006,008 DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attaghed if mare space Is required) CERTIFICATE HOLDER. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE . THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Morristown ACCORDANCE WITH THE POLICY PROVISIONS. 200 South Street, PO Box 914 Office of Mayor/Administrator Morristown, NJ 07963 AUTHORIZED REPRESENTATIVE i ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD © 1988-2015 ACORD CORPORATION. All rights reserved,

_ PROGRESSUE P.O, Box 94739 ‘Cleveland, OH 44101 1-800-895-2886 Policy number: 958488296 Underwritten by: Drive New Jersey Insurance Company NAIC Number: 11410 May 27, 2022 Page 1 of 1 Certificate of Insurance Evan Dilluvio 976 Old School House Road Blairstown, NJ 07825 Tosured ss se cs sesesseeses hae Evan Dilluvio PROG COMMERCIAL kara Venella PO BOX 94739 976 OLD SCHOOL HOUSE ROAD CLEVELAND, OH 44101 BLAIRSTOWN, NJ 07825 This document certifies that insurance policies identified below have been issued by the designated insurer to the insured named above for the period(s) indicated. This Certificate is issued for information purposes only. it confers no rights upon the certificate holder and does not change, alter, modify, or extend the coverages afforded by the policies listed below. The coverages afforded by the policies listed below are subject to all the terms, exdusions, limitations, endorsements, and conditions of these policies. Liability coverage may not apply to all scheduled vehicles, Uninsured/linderinsured BD Description of Location/Vehides/Special Items Scheduled autos only 2016 TOYOTA PRIUS C JTDKDTB38G1 128884 (included in combined single limit w/$500 Ded) Medical Expense $15,000 Extended Medical Payments $1,000 Comprehensive $1,000 Ded Callision $1,000 Ded Ky Form 5241 (05/16)

STATE OF NEW JERSEY BUSINESS REGISTRATION CERTIFICATE BE} DEPARTMENY OF TREASURY] B} DIVISION OF REVENUE BR PO BOX 2: Pi TRENTON, J 9n648-0252 | TAXPAYER NAME: TRADE NAME: ! DILLUVIO,EVAN W TREE CONSULTING ARBORICUL TURE ADDRESS: SEQUENCE NUMBER: 345. ZION ROAD 4 . HILLSBOROUGH NJ 08644 _ Heoe80 EFFECTIVE DATE: ISSUANCE DATE: “ograwor o2ranror 9. 2D. . “Acti ‘Now Seaey Bion of Reverie:

oe ; es State of New Jersey . hey ath oo, . =" Board of Tree Experts Tree Expert and Tree Care Operator Licensing Act , Tits Certifies That , EVAN W DILLUVIO LTE #504 In.Acconitance With The Provistons. Of Chapter 237, PL. 2009, ‘Has Been Duly : Bxumined Or Accepied In Reciprocity And Licensed To Practice As A Licensed Tree Expert Mg Tt in Withess Whereof, | have pain sonasheanhannht Licensed e State of New Jersey to be pam phinn ad. Steve M. Chisholm, Expiration Date President Board of Tree Experts Thi catifcre may Not be transferred or axignad andl may be revoked or suspended for causa by the Board of Tree Expert

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