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HomeMy WebLinkAbout22 CHALLENGE 22CHL-1 CIP D 1 ACORO" DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/26/2017 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(les) 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 FAX 502-897-1533 6100 Dutchmans Lane 10th Floor (A/C,No,Ext): (A/C,No): P 0 Box 7669 E-MAIL sstivers@kielyhines.com Louisville,KY 40257-0669 ADDRESS: Sharon K.Stivers INSURERS AFFORDING COVERAGE NAIC# INSURER A:Mount Vernon Fire Ins.Co. 26522 INSURED 22 Challenge Corporation INSURER B: Ernest McCurdy 4263 Sun Rise Drive INSURERC: Sellersburg,IN 47172 INSURER D: 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 TYPE OF INSURANCE AD DL SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS R D MM/DD/YYYY MM/DD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 CLAIMS-MADE F_X]OCCUR CL2711042 05/20/2017 05/22/2017 DAMAGE TO RENTED $ 100,000 MED EXP(Any oneperson) $ 1,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY El jpeT El LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED(Ea ccident)SINGLE LIMIT $ ANY AUTO BODILY INJURY Perperson) OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED I I RETENTION$ $ WORKERS COMPENSATION PEROTH- AND EMPLOYERS'LIABILITY Y/N 1T ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT OFFICER/MEMBER In NH)EXCLUDED? N/A E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $ E3 9CfIgt1O OF ZER4TIPart SNan ACQpI.t9S/VE InSU�e(IORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Big 4 Station Park ACCORDANCE WITH THE POLICY PROVISIONS. Jeffersonville,IN 47130 AUTHORIZED REPRESENTATIVE 00 k. .dYwtu--- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ;"Mv SMALL EVENT PERIMIT APPLICATION �RS��• For events,black parties,parades,walks,rwrs and public rallies wifh a maximum attendance under 500 people t � Return to:Jeffersonville Parks Department,500 Quartermaster Ct.,Jeffersonville,IN 47130 Additional information contact: 812-285-6440,Fax:812-285-6481 EVEN1'NAME: -22CHALLE,NGE-10 RUCKMARCH- Official name of festival or event CONTACT/PRODUCER: SCOTT A.HAM Person Wor Producer to be-ccinfacled.regarding event CONTACT ADDRESS: 3013 SYCAMORE DRIVE NEW ALBANY, IN 47150 treet city Stat, Zip CONTACT INFO: 502-396-7460 502-396-7460 812-246-6503 scott.a.ham(cptnail.com Dav Phone Cell Phone Fax mail EVENT INFORMATION Event location address: OVERLOOK/RIVERFRONT THEN ROUTE TO BIG 4 BRIDGE RAMP THEN FALLS OF THE OHIO AND BACK TO OVERLOOK Starting Date: 05/20 / 20 10 Time: 07:30_AM Ending Date: 05120 /_2016 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. 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 ENCONIPASSES MORE THAN(4)CITY BLOCKS OR MAJOR THOROUGHFARE COMPLETE LARGE EVENT APPLICATION) - _Block Party_Parade_Motorcade_Rally/Public Gathering X Walk/Run Other NOTE:WE DO NOT WISH TO CLOSE ANY STREETS.WE WILL RELEASE RUCK MARCHING PARTICIPANTS AND WE GVLLL HAVE THEM STAGGER AND USE SIDEWALKS AND BE COURTEOUS TO PUBLIC ATTENDEES OF THE ARCA TO INCLUDES LOCAL RESTAURANTS (*NOTE:LAST YEAR WE DID HAVE SOM_E 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 al I 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 applicanl/lvent 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 auomeys'fees,arising out of or resulting,directly or indirectly,from the Applicant/Event Producer's(or Appicant/Event Producer's subcontractors.if any)perfonnance or breach of the contract provided that such claim,damage,loss of expenses is:(I)attributable to personal injury, bodily in.iury,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 noway 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* s and procedures may result in the immediate revocation of the approved permit and/or refusal to issue a permit in the future. XZ Z Dattt e / V e1ptit o ice tre Public Works/Street FarKs atety