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Home My WebLink AboutFIDOWALK SMALL EVENT PERMIT APPLICATION For events,block parties,parades,walks,runs and public rallies with a maximum attendance under 500 people Return to:Jeffersonville Parks Departmeat,500 Quartermaster Ct.,Jeffersonville,IN 47130 Additional information contact: 812-285-6440,Fax: 812-285-6481 EVENT NAME: �� wo K-- Official Official nameof festival or event CONTACT/PRODUCER: �,TJ 1�q r �� 1t� Person&Jo Producer to be contacted regarding event t CONTACT ADDRESS: -z d Street �/ city State ,St/ate ^/ Zip CONTACT INFO: �� b I Z,qgr1- ` ,3 7 / /i'/i LL��ZC�CN°�Z�� Day Phone Cell Phone Fax E-mail J EVENT INFORMATION . � r f Event location add res : �Letrs{tf) 1 I U Y G LI,ej (/�;L� Starting Date: l�- / / Time: AM Ending Date: t�/ / Time:__1_:_a0 —I : Total attendance expected: Q0 Rain/Cancellation Policy ._ mc(A b'lr h,the) Provide alternative dates,times and locations of event,if applicable.Must contact city coordinator ASAP if day of event. FEES to be paid at time of application made payable to Jeffersonville Parks Department—SMALL EVENT.$40(500&under) (IF ATTENDANCE OVER 500 OR EVENT ENCOMPASSES MORE THAN(4)CITY BLOCKS OR MAJOR THOROUGHFARE COMPLETE LARGE EVENT APPLICATION) _ _Blockarty Parade_Motorcade Rally/Public Gatherin. 1 un Othe� X1.1 h TW J STREET CLOSINGS OR AREA TO BE USED Additional Information REQUIRED from event producer/contact: • Notify affected business and residents of street closures • Provide your own barricades for all blocked&/or street closures.Check Yellow Pages under"Barricades" ------ • Provide map showing streets to be blocked,or if a run/walk a mai of your route • Provide a Certificate of Insurance listing the City of Jeffersonville as an additional Insured for$1,000,000 HOLD HARM LESS AND IDEMNIFTCATION CLAUSE The applicant/Event Producer shall indemnify,hold harmless and defend the City of Jeffersonville and the Jeffersonville Parks&Recreation Department,their elected and appointed officials,employees,agents and successors in interest from all claims,damages,losses and expenses including attorneys'fees,arising out of or resulting,directly or indirectly,from the Applicant/Event Producer's(or Applicant/Event Producer's subcontractors,if any)performance or breach of the contract provided that such claim,damage,loss of expenses is:(1)attributable to personal injury, bodily injury,sickness,death,or to injury or destruction of property,including the loss of use resulting there from,or breach of contract,and(2)not caused by the negligent act or omission or willful misconduct of the City of Jeffersonville or the Jeffersonville Parks&Recreation Department,their elected and appointed officials and employees acting within the scope of their employment.This Hold Harmless and Indemnification Clause shall in no way be limned by any financial responsibility or insurance requirements and shall survive the-termination of the Small Event Permit Application. Only appli t/s/ good standing with the City of Jeffersonville will be considered for Approval.Any misrepresentation in this application or deviation om a final approval spec' c tions and �tivities described herein or failure to abide by all Federal,State and City of Jeffersonville laws, ordin ,poli ies and procedures m.y r sult in th=ediate revocation of the approved permit and/or refusal to issue a permit in the future. ALI o2z �SIJGNATURE REQUIRED Date Receipt# e-,tr 0 lc� oltce Fire Public Works/Street Pares Safety i ''i r M° C) M (V M M .NCli -I 'I' t � �p Qe�\5` •� �' :i OO � L z O X95` L any hManlua.N �� [.{ Clark St • .. �� '`�" � ,� .> nyp �- f0 L = C ® co !uulpul - . �e® 1@Wt Q IC j666 L O i- JD c ((( o qurulz An w�% a^v pmns!py .. �a5p, ap + > L O (n ahylawaoM d C> ' >,S laluaC �J 0-4--111 � L3 > n +� O V co \ + L Ui Y - �anry ot40 L- Cl) velVIA O F € - w .y O ,me Q cu ti N (� > f0 fu C_0 bA srse v� A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM1DDNYYY) 04/07/2017 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 CONTACT NAME: Sandy Morris Rural Insurance Agency, Inc. PHO(AICNo ext: 3f7-692-7016 aC No: 317-692-8450 225 South East Street E-MAIL Indianapolis Indiana 46206 ADDRESS: sandy.morris@infarmbureau.com PR OUCER CUSTOMER ID: INSURERIS)AFFORDING COVERAGE NAIC V INSURED INSURER A: Nationwide Mutual Insurance Company 23787 XI BETA ALPHA INSURER B: 2104 Augusta Dr. INSURERC: Jeffersonville, IN 47130 A Member of the Sports,Leisure&Entertainment RPG INSURER D: INSURER E: INSURER E: COVERAGES CERTIFICATE NUMBER: W01009253 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. INSR1 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSO WVD MM/DDNYYY MM/DD A X COMMERCIAL GENERAL LIABILITY 6BRPG0000006055900 04/08/2017 04/09/2017 EACH OCCURRENCE $1,000,000 MADE S- FX]OCCJR 12:01 AM EDT 12:01 AM AMA $1,000,000 PREMISES Ea Occurrence MED EXP(Any one person) $55,000 PERSONAL&ADV INJURY $11,000,000 GENERAL AGGREGATE $5,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS—COMPIOPAGG $1,000,000 POLICY ❑PRO- ❑LOC JECT PROFESSIONAL LIABILITY OTHER: LEGAL LIAR TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLELIMIT Ee accident ANY AUTO BODILY INJURY(Per parson} OWNED AUTOS e AUTOSULED BODILY INJURY(Per accident) HIRED NON•OWNED P DAMA AU TOS ONLY AUTOS ONLY Peraccldentl NOT PROVIDED WHILE IN HAWAII UMBRELLA LIABOCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND NIA PER OTHER EMPLOYERS'LIABILITY STATUTE ANY PROPRIETOWPARTNERI YIN ELL EACH ACCIDENT EXUTIVE DED?( CEWMEMBER ❑ E.LDISEASE—EAEMPLOYEE EXCLUDED?(Mandatory In NH) If yes,describe under DESCRIPTION E.L.DISEASE—POLICY LIMrr OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS 68RP000D0006055900 04/08/2017 04109/2017 PRIMARY MEDICAL 12:01 AM EDT 12:01 AM I EXCESS MEDICAL $25,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached U morn space is required) Legal Liability to Participants(LLP)limit is a per occurrence limit. Event Name:XI BETA ALPHA walk Type of Event:Walk Distance.5K Event Date(including ancillary events and set-upltear-down):4/8/2017 to 4/8/2017 Number of Participants:200 Event Location:Jeffersonville River Front CERTIFICATE HOLDER CANCELLATION Evidence of Coverage 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 /nom Coverage is only extended to U.S.events and activities. " NOTICE TO TEXAS INSUREDS:The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas ACORD 25(2016103) p JSBB-2015 ACORD CORPORATION. All lights reserved. The ACORD name and logo are registered marks of ACORD