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HomeMy WebLinkAboutREHEARSAL IN THE PARK/WAKE UP EVERYBODY 74, PEAR 1 3 2017 o: D S¢ CIf�� rr]ERMIT APPLICATION For events,block parties,parades,walks,runs and public rallies with a maximum attendance under 500 people Ail 3 1 2017 tl �ky t r' Return to:Jeffersonville Parks Department,500 Quartermaster Ct.,Jeffersonville,IN 47130 Additional information contact: 812-285-6440 Fax: 812-285-6481 — r � 5�-� N ThF_ Pwr-X- OA, -ve �� �uL EVENT NAME: � �'� • Official n e of festival or event CONTACT/PRODUCER:I �� R o u t ; � Person Wor Producer to be,�-tgap �cteed regarding event � CONTACT ADDRESS: 15 r' /I Street I City State //v �� re c15 �� k_ l 15- vA4 ` S tJ y CONTACT INFO: E-mail ' Day Phone Cell Phone Fax EVENT INFORMATION 5�h Event location ddr ss: iC Startingpa . Date: /� / % / Time: :��I M Ending Date:�/� / / /Time: VMf— co Total attendance expected: Rain/Cancellation Policy P&J AQ s Or- �P1 rr Provide alternative dates,times and locations of event,if applicable.Must contact city coordinator ASAP if day of even. FEE to be paid at time of application made payable to Jeffersonville Parks Department—SMALL EVENT$x-50(500&under) (IF ATTENDANCE OVER 500 OR EVENT ENCOMPASSES MORE THAN(4)CITY BLOCKS OR MAJOR THOROUGHFARE DIFFERENT EVENT APPLICATION Ar FEES MAY APPLY) _Block Party Parade_Motorcade V Rally/Public Gathering_Walk/Run , r ' Other r twillE JUE2 4- P1 it STREET CLOSINGS OR AREA TO BE USED Additional Information REQUIRED from event producer/contact: • Notify affected business and residents of street closures • Provide your r�vnn barricades for all blocked&/or street closures.Check Yellow Pages under"Barricades"OL • Provide Wlowing streets to be blocked,or if a run/walk a map of your route FA W • 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 app "dal specifications and activities described herein or failure to abide by all Federal,State and City of Jeffersonville laws, ordinances olicies and o ed res ma result in the immediate revocation of the approved permit and/or refusal to issue a permit in the future. SIG A IRM REQUIRED Date Receipt# �� - W v6AII P e Fire Publ' orks/Street Parks Safety . � CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �./ 04/06/2017 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 NAMT CT E: Cathy J Dupuis Church Mutual Insurance Company acNN Ext: 1-800-554-2642 Option 1 ac No: 855-264-2329 3000 Schuster Lane E-MAIL cs2@churchmutual.com ADDRESS: P.O.Box 357 INSURERS AFFORDING COVERAGE NAIC# Merrill WI 54452 INSURERA: Church Mutual Insurance Company 18767 INSURED FIRST TRINITY BAPTIST CHURCH INSURER B: INSURER C: 1506 SPRING ST INSURER D: INSURER E: JEFFERSONVILLE IN 47130-2940 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICYNUMBER MMIDD/Y MMID X COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ 1,000,000 IX OCCUR DAMAGE TO RENTED CLAIMS-MADE PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 15,000 A N 0051001-02-723618 09/11/2014 09/11/2017 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY❑JECT D LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECU I IVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (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 I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached N more space is required) Evidence of Liability Insurance for the Rehearsal in the Park on June 3,2017 at Henry Lansden Park,201 East 15th Street,Jeffersonville,IN 47130. SRAP 510. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF JEFFERSONVILLE ACCORDANCE WITH THE POLICY PROVISIONS. 500 QUARTERMASTER CT STE 250 AUTHORIZED REPRESENTATIVE /� JEFFERSONVILLE IN 47130-3672 �� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD