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HomeMy WebLinkAboutCHILDREN MIRACLE NETWORK GST Y OA fit, '1 10111-,!lez,. oWb - ,c sow CITY EVENT PERMIT APPLICATION For events,block parties,parades,walks,runs and public rallies Return to:Jeffersonville Parks Department,500 Quartermaster Ct.,Jeffersonville,IN 47130 Additional information contact:812-285-6440,Fax: 812-285-6481 EVENT NAME: Children's Miralce Network Car Show-Sponsored by:RE/MAX FIRST Official name of festival or event CONTACT/PRODUCER: Bill Burns Person&/or Producer to be contacted regarding event CONTACT ADDRESS: 2123 Veterans Pkwy,Jeffersonville,IN 47130 Street City State Zip CONTACT INFO: Bill Burns 502-649-8744 Day Phone Cell Phone Fax E-mail EVENT INFORMATION Event location address: Mullberty Street in Jeffersonville-Maple to edge of walking bridge Date:_07_/_14_/_18_Day of week: Sat. Time: 7am-2:00pm _M Ending Date: 7.14.18 / / Day of week: _IttukR bAl Time: _M Total attendance expected: 100 ish cards Rain/Cancellation Policy Rain moves us to Sunday July 15, 2018 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 GatheringWalk/Run Other_Car show 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 INDEMNIFICATION 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:(l)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. GkiI 142 REMAX-3 OP ID:TS A RD CERTIFICATE OF LIABILITY INSURANCE DATE(MMrOD/YYYY) 06/1312018 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 Brian C Smith Callistus Smith Agency,Inc. 3415 Paoli Pike AArCNE No,Sail:812-944-7711 (A FAX o 812-945-0281 Floyds Knobs,IN 47119 E-MAIL ESS: ODR Brian C Smith P&C — _ INSURERS)AFFORDING COVERAGE NAIC lI INSURER A:West Bend Mutual Ins Co 115350 INSURED Childrens Miracle Network INSURER B: —I Car Show I ReMax First -- — — 2123 Veterans Pkwy INSURER c Jeffersonville,IN 47130 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 I - !AWL swill POLICY EFF POLICY EXP 1 LTR! TYPE OF INSURANCE INSO WVO POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY)I LIMITS A j X COMMERCIAL GENERAL ELIABILITY I f EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE LX {{OCCUR Y A47210307/14/2018 07/15/2018 PREM SES EaEoccuGE TO Errence) $ 100,000 MED EXP(Any one person) $ excluded PERSONAL S.ADV INJURY S 1,000,000 GEN.AGGREGATE LIMIT APPLIES PERT GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER. S AUTOMOBILE LIABILITY 3 {EOM81Nde0t�INGLE LIMIT ANY AUTO BODILY INJURY(Per person) S ALL OWNED F-1 SCHEDULED AUTOS t AUTOS I BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ S UMBRELLA LIAR ` OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION PER 1OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) I E.L.DISEASE-EA EMPLOYEE!S If yes,descre under I E.L.DISEASE-POLICY LIMIT`S DESCRIPTION OF OPERATIONS below r E DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Event:Childrens Miracle Network Hospitals Car Show/Motor Cycle Run Sponsored by Re/Max First July 14-15, 2018 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. Jeffersonville Parks Depart 500 Quartermaster Court AUTHORIZED REPRESENTATIVE Jeffersonville,IN 47130 ©1988-2014 ACORD CORPORATION. All rights reserved.