CERTIFICATE OF INSURANCE COVERAGE

NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW

PART 1. To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier
1a. Legal Name & Address of Insured (use street address only) 1b. Business Telephone Number of Insured
AJ PRO CONTRACTOR LLC 646-992-8471
20 W 47TH STREET UNIT #601
NEW YORK, NY 10036
1c. Federal Employer Identification Number of Insured
or Social Security Number
Work Location of Insured (Only required if coverage is specifically limited to
certain locations in New York State, i.e., Wrap-Up Policy) 933071557

2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company

3b. Policy Number of Entity Listed in Box "1a"

DBL736083
3c. Policy effective period
01/21/2025 to 01/20/2026
4. Policy provides the following benefits:
✘ A. Both disability and paid family leave benefits.
B. Disability benefits only.
C. Paid family leave benefits only.
5. Policy covers:
✘ A. All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law.
B. Only the following class or classes of employer's employees:

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 NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above.

Date Signed 1/22/2025 By

(Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier)

Telephone Number 516-829-8100 Name and Title Leston Welsh,Chief Executive Officer
IMPORTANT: If Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS
Licensed Insurance Agent of that carrier, this certificate is COMPLETE. Mail it directly to the certificate holder.

If Box 4B, 4C or 5B is checked, this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the NYS
Disability and Paid Family Leave Benefits Law. It must be emailed to [email protected] or it can be mailed for
completion to the Workers' Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200.
PART 2. To be completed by the NYS Workers' Compensation Board (Only if Box 4B, 4C or 5B have been checked)
State of New York
Workers' Compensation Board
According to information maintained by the NYS Workers' Compensation Board, the above-named employer has complied with the
NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers' Compensation Law) with respect to all of their employees.

Date Signed By
(Signature of Authorized NYS Workers' Compensation Board Employee)

Telephone Number Name and Title

Please Note: Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance
agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form.

DB-120.1 (12-21)
DB-120.1 (12-21)
 Additional Instructions for Form DB-120.1

By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business
referenced in Box 1a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave
Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate) to
the entity listed as the certificate holder in Box 2.

The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a
policy is cancelled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of
premiums that cancel the policy or eliminate the insured from coverage indicated on this Certificate. (These notices may
be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier
or its licensed agent, or until the policy expiration date listed in Box 3c, whichever is earlier.

This Certificate is issued as a matter of information only and confers no rights upon the certificate holder. This Certificate
does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities
beyond those contained in the referenced policy.

This Certificate may be used as evidence of a NYS disability and/or Paid Family Leave benefits contract of insurance only
while the underlying policy is in effect.

Please Note: Upon the cancellation of the disability and/or Paid Family Leave benefits 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 Insurance Coverage for NYS disability and/
or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory
coverage requirements of the NYS Disability and Paid Family Leave Benefits Law.

NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW

§220. Subd. 8
(a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any
permit for or in connection with any work involving the employment of employees in employment as defined in this article,
and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such
permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the
payment of disability benefits and after January first, two thousand and twenty-one, the payment of family leave benefits
for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating
any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to
any such employee if so employed.

(b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into
any contract for or in connection with any work involving the employment of employees in employment as defined in this
article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into
any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that
the payment of disability benefits and after January first, two thousand eighteen, the payment of family leave benefits for
all employees has been secured as provided by this article.

DB-120.1 (12-21) Reverse