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HomeMy WebLinkAbout22 CHALLENGE 10 K RUCK MARCH CITY EVENT PERMIT APPLICATION For events,block parties,parades,walks,runs and public rallies Return to:Jeffersonville Parks Dept anent,500 Quartermaster Ct.,Jeffersonville,IN 47130 Additional information contact: 812-285-6440,Fax: 812-285-6481 EVENT NAME: 22CHALLENGE 10K RUCK MARCH Official name of festival or event CONTACT/PRODUCER: SCOTT A.HAM Person&/or Producer to be contacted regarding event CONTACT ADDRESS: 3013 SYCAMORE DRIVE NEW ALBANY, IN 47150 Street City State Zip CONTACT INFO: 502-396-7460 502-396-7460812-246-6503_scott.a.ham a@gmail.com Day Phone Cell Phone Fax E-mail EVENT INFORMATION Event location address: OVERLOOK/RIVERSIDE TO BIG 4 BRIDGE TO FALLS OF THE OHIO AND BACK Date: 05 / 18 / 19 Day of week: SATURDAY Time:_07:30_AM Ending Date: 05 / 18 / 19 Day of week: SATURDAY Time: 1:00 PM Total attendance expected: <500 Rain/Cancellation Policy NO RAIN CANCELLATION= EVENT TO BE RAIN OR SHINE 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 XWalk/Run Other NOTE:WE DO NOT WISH TO CLOSE ANY STREETS.WE WILL RELEASE RUCK MARCHING PARTICIPANTS AND WE WILL HAVE THEM STAGGER AND USE SIDEWALKS AND BE COURTEOUS TO PUBLIC ATTENDEES OF THE AREA TO INCLUDES LOCAL RESTAURANTS. (*NOTE:LAST 3 YEARS WE DID HAVE SOME VEHICLE DELAYS CAUSED BY OUR EVENT AT THE INTERSECTION OF SPRING STREET&RIVERSIDE DRIVE) 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,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 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 specifications and activities described herein or failure to abide by all Federal,State and City of Jeffersonville laws, ordinances, •i i ies and procedures may result in the immediate revocation of the approved permit and/or refusal to issue a permit in the future. X 4 in •.' 2011 //SIGNATURE REQUIRED qq ��--t�� Date Receipt# - I 6,2e" LA.Z4ikic ,slice Fire Public Works/Street Parks Safety ___—...4,10 22CHL-1 OP ID: K1 A�o�RI CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYYY) 02/11/2019 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 502-893-2020 CONTACT Sharon K.Stivers NAME: Kiely, Hines&Assoc.Ins. PHONE 502-893-2020 I FAX 502-897-1533 6100 Dutchmans Lane 10th Floor (NC,No,Ext): (A/c,No): P 0 Box 7669 a DRRESS:sstivers@kielyhines.com Louisville,KY 40257-0669 Sharon K.Stivers INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Mount Vernon Fire Ins.Co. 26522 INSURED INSURER B: 22 Challenge Corporation Ernest McCurdy INSURER C: 4263 Sun Rise Drive Sellersburg,IN 47172 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. INSR ADDL SUBR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP IMM/DD/YYYYI (MM/DD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X CL274822 05/18/2019 05/20/2019 DAMAGE TO (Ea occurrence) $ 100,000 MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY j LOC PRODUCTS-COMP/OP AGG $ included OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT JEa accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS yy ED BODILY INJURY(Per accident) $ _ AUTOS ONLY _ AUTOOS ONLY ((Per aca dentD)AMAGE $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER H AND EMPLOYERS'LIABILITY STATUTE ERY/N ANY ICER/MEMBE EXCLUDERD4ECUTIVE N/A E.L.EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Jeffersonville Parks Department is listed as an Additional Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Jeffersonville Parks De t THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p ACCORDANCE WITH THE POLICY PROVISIONS. 500 Quartermster Ct. Jeffersonville, IN 47130 AUTHORIZED REPRESENTATIVE ,,S14,- . k. ;v.-- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD