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HomeMy WebLinkAboutEURO DISTRICT ',Wt. � ' o ` ,,`` �: 1 � SO CITY EVENT PERMIT APPLICATION For events,block parties,parades,walks,runs and public rallies with a maximum attendance under 500 people etirj k011,1; Return to:Jeffersonville Parks Department,500 Quartermaster Ct.,Jeffersonville,IN 47130 Additional information contact:812-285-6440,Fax: 812-285-6481 O\S \EVENTNA : — / 1.. Dl 1-- 1_Official namr of festival or\ f\ —\ e ventt , CONTACT/PRODUCER: \ ' O {nT )/ �ers Producer tete contacted regdina event CONTACT ADDRESS: Wb\ k I�^ \1, 1�' C. \..u t�)`v�tl , Au I Street ,/ City Stat Zip CONTACT INFO: \I 2 )1 ?- -2\ n i 1 \\D t\ Y A t ,. (A1\ • ��rn Day Phone CeII Phone Fax E-mar EVENT INFORMATIOI - Event locationd�lr• s: off i. Starting Day '1' I ',k I)ate. A / iLk l •Time: I : 10( M Ending Date: (06t. 1A /1, Time:\O.?rY\ • M Total attendance expected: * $ 1,,,, Rain/Cancellation Policy \�1t (1,\A( OcI Provide alternative dates,times and locations of event,if applicable.Must contact city coordinator ASAP if day of event. FEE to be paid at time of application made payable to Jeffersonville Parks Department—SMALL EVENT$150(500&under) (IF ATTENDANCE OVER 500 OR EVENT ENCOMPASSES MORE THAN(4)CITY BLOCKS OR MAJOR THOROUGHFARE DIFFERENT EVENT APPLICATION AND FEES MAY APPLY) Block Party Parade_Motorcade_Rally/Public Gathering_Walk/Run Other (' C( C> 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 map of your route • Provide a Certificate of Insurance listing the City of Jeffersonville as an additional Insured for$1,000,000 HOLD HARMLESS AND IDEMNIFICATION 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,siclnless,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 limited by any financial responsibility or insurance requirements and shall survive the termination of the Small Event Permit Application. Only applicants in good standing with the City of Jeffersonville will be considered for Approval.Any misrepresentation in this application or deviation from the final approval specif . .ns and activities described herein or failure to abide by all Federal,State and City of Jeffersonville laws, ordinances, .olio-s and .ro eaur-s :y 7e-, •. immediate revocation of the approved permit and/or refusal to issue a permit in the future. - ,� 4 /21 / \1 11,1A-\\i X SIGNATU• • u WED Date . Receipt# _ ��Age0/y II '1,d ' 40! / Police irePublic Works/Street Par Safety k bi k) P0 k.rm^ ` i, R -," ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE TE( M/2018Y) 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 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: HCC Specialty "AJC.No.EXn: FAX 401 Edgewater Place, Suite 400 DRIESS: PRODUCER Wakefield, MA 01880 CUSTOMER ID#: _._ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: U.S. Specialty Insurance Company 29599 Dinah Chmielewski INSURERB: United States Fire Insurance Company 21113 8801 High Point Circle INSURERC: Louisville, KY 40299 INSURERD: INSURER E: INSURER F: 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 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. ILTRR ADDL TYPE OF INSURANCE INSR SWVD POLICY NUMBER UBRT(MM/PODD/YYYY)Y EFF POLICY EXP LIMBS ( ) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X SEL333128721 01/11/2018 04/17/2018 DAMAGE TO RENTED 300,000 PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 X Host Liquor PERSONAL&ADV INJURY $ 1,000,000 g X Medical Expense US966924 01/11/2018 04/17/2018 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY JELOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION - VVL.SIAIIMT- -ER AND EMPLOYERS'LIABILITY TORY LIMITS ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The Certificate Holder is added as Additional Insured with respects to our Insured's operations only. This insurance is primary and non-contributory as required by written contract. This coverage is with respect to The Euro District event to be held 04/14/2018-04/14/2018 at Big Four Station Park&Pedestrian Bridge Jeffersonville IN CERTIFICATE HOLDER CANCELLATION City Of Jeffersonville IN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 500 Quartermaster Ct-Suite 250 IN ACCORDANCE WITH THE POLICY PROVISIONS. Jeffersonville, IN 47130 AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved.