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HomeMy WebLinkAboutRELAY FOR LIFE _c J� (-jo „�;1T_•Y.-;Dom,,. .� , RsoN .CITY EVENT PERMIT APPLICATION por events,block parties,parades,walks,runs and public rallies with a maximum attendance under 500 people i Return to:Jeffersonville Parks Department,500 Quartermaster Ct.,Jeffersonville,IN 47130 Additional information contact:812-285-6440,Fax: 812-285-6481/ EVENT NAME: L I D GI a ` O a v 1 Official name of festival or event CONTACT/PRODUCER 01 I r, Person Wor Producer to be contacted regarding event CONTACI'ADpRESS: .l Le4o 1 d& FU�-m J • I o� o, �-1�Z-23 Street City State Zip CONTACT I I O: 5w j —mill 0 �✓��' S �"t 7th FL , PAtr4one Cell"Phone Fax' E-mail )EVENT INFO404TION _ Event location address W �i 6kL LT. (�j'} Vt fi(tt � Starting Dated �M Ending Date: /ZD/ t Total attendance exliecte',.; I Rain/Cancellation Policy Provide alternative dates,times and locations of event,if iplicable.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) (1F ATTENDANCE OVER 500 OR EVENT ENCOMPASSES MORE THAN(4)CITY BLOCKS OR MAJOR THOROUGHFARE COMPLETE LARGE EVENT APPLICATION) / _Block Party Parade_Motorcade_RaIly/Ptlblic Gathering alk/Ruri 1; Other 1 le AFA. nti I STREET CLOSINGS OR AREXTO BE USED Additional TtifMmation REQUIRED from event producer/contact: (__ t Notify aff&ted_basiness and residents of street closures `Provideyo�u owfi barricades for all blocked&/or street closures. Check Ye11ow-Pages under"Barricades" � `Provide map showing streets to be blocked,or if a run/walk a map of your route • Provide a Certificate of Insurance listing the City of Jeffersonville as an additional Insured for$1,000,000 HOLD HARN/FT "" 1IFICATION CLAUSE a The��-" hold harmless and defend the City of Jeffersonville and the Jeffersonville Parks&Recreation Dt als,employees,agents and successors in interest from all claims,damages,losses and expenses C inc. Iting,directly or indirectly,from the Applicant/Event Producer's(or Applicant/Event Producer's subt � f the contract provided that such claim,damage,loss of expenses is:(1)attributable to personal injury, bodi. ;truction of property,including the loss of use resulting there from,or breach of contract,and(2)not 1 caust > 1 misconduct of the City of JeffersonvilIc or the Jeffersonville Parks&Recreation Department,their r electe �`� r�„�,1� Ing within the scope of their employment.This Hold Harmless-aril Indemnification Clause shall in no wad �`y R (? )r insurance requirements and shall survive the termination of the Small Event Permit Application. r Only ap 'J +of..�cn the City of Jeffersonville will be considered for Approval.Any misrepresentation in this application or deviation _- W approvalspectlications and activities described herein or failure to abide by all Federal,State and City of Jeffersonville laws, ordinances oIt ies and procedures a result in the immediate revocation of the approved permit and/or refusal to issue a permit in the future. x /0 / 3f / SIGNATURE REQUI D Date Receipt# J ° / once r Publ>1 Works/Stre t Parks Safety t I 'o . @. � l 139199 ACORV CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 5/16/2017 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: Jennifer Lefler Commercial Lines—(404)923-3700 PHONE : 404 923 3663 877-362-9069 -(AIC.No.Ext - __ (AIC,No): Wells Fargo Insurance Services USA,Inc. E-MAIL enni923-lefler wellsfar o.com ADDRESS: g 3475 Piedmont Road NE,Suite 800 INSURERS)AFFORDING COVERAGE NAIC# Atlanta,GA 30305 2886 INSURER A: Federal Insurance Company 20281 INSURED INSURER B American Cancer Society, Inc. 250 Williams Street INSURER C: INSURER D: INSURER E: Atlanta,GA 30303 INSURER F COVERAGES CERTIFICATE NUMBER: 11778194 REVISION NUMBER: See below 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. IN RI ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY) 1MM/DD/YYYYI LIMITS XCOMMERCIAL GENERAL LIABILITY D9/Ol/2016 09/01/2017 A X 35943463 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR PREMISES Ea oDA AG TO ccurrence) $ 300,000 — - --- –.— MED EXP Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER* GENERAL AGGREGATE $ 25,000,000 X POLICY D PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETORIPARTNER/EXECUTIVE OFFICER/M EMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT $ (Mandatory to NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Contract#45830 Relay For Life of Clark County Clark County May 20,2017 (rain date June 10) (mm) Certificate holder is included as an additional insured in accordance with the terms and conditions of the general liability policy and only if required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION City of Jeffersonville SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 500 Quartermaster Court THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Jeffersonville, IN 47130 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ©1988-2015 ACORD CORPORATION. All rights reserved.