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HomeMy WebLinkAbout2014 Police lease schedule 17 pay request 9 Lease 2014 — Sch # 17 (Police Dept.) Payment Request # 2014-09 EXHIBIT A PAYMENT REQUEST FORM/ACCEPTANCE CERTIFICATE The Escrow Agent is hereby requested to pay from the Acquisition Fund established by the Escrow Agreement dated as of February 18,2014 by and among the Escrow Agent,the Lessee and Lessor,to the person or corporation designated below as Payee, the sum set forth below in payment(of all/of a portion)of the Acquisition Costs described below. The amount shown below is due and payable under a purchase order or contract with respect to the Equipment described below and has not formed the basis of any prior request for payment. In addition,the undersigned acknowledges delivery,installation and receipt in good condition,and hereby accepts the Equipment described on the attached invoices. Payee: Don Hinds Ford Amount: $481,942.00 Description of Equipment Item Cost: 18 Police Vehicles Dated: June 18, 2014 LESSEE: City of Carmel One Civic Square Carmel,IN 46 2 Y: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Don Hinds Ford 12610 Ford Drive Fishers, IN 46038 PAGE I Ac® CERTIFICATE OF LIABILITY INSURANCE DATE(MM4DD)YYYY) 4/21/2014 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). CONTACT PRODUCER NAME: Marianne Uban Hylant Group ra/c°.No.Ext1:317-817-5136 FAX x:317 817 5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADDRESS:marianne.uban @hylant.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: - •.._ - I A -nce Co , 5615 INSURED CARME80 INSURER B City of Carmel INSURER C: One Civic Square INSURER D: Carmel, IN 46032 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:970829312 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 ADM SUER POLICY EFF POLICY EXP TYPE OF INSURANCE W I LTR INSR VD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYYI LIMITS A GENERAL LIABIUTY Y ZLP14T62033 1/1/2014 1/1(2015 EACH OCCURRENCE $2,000,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $50,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) SExcluded PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO- LOC I$ JECT A AUTOMOBILE LIABILITY H8103036P64ACOF14 1/1/2014 V1/2015 COMBINED SINGLE LIMIT (Ea accident) $2,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS — AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) _ X Comp X Coll Comp/Coll Ded $2,500 UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'UABILITY V I N TORY_LIMLTS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? N I 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 I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) ADDITIONAL NAMED INSUREDS: CARMEL CLAY PARKS BUILDING CORPORATION; CARMEL CLAY BOARD OF PARKS& RECREATION; CARMEL REDEVELOPMENT COMMISSION; CARMEL REDEVELOPMENT AUTHORITY; CARMEL CITY CENTER COMMUNITY DEVELOPMENT CORPORATION Certificate Holder is an Additional Insured re: Various Police Equipment/Vehicles CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Huntington National Bank& It's Assignors&Assignees ACCORDANCE WITH THE POLICY PROVISIONS. do American Lease Insurance 654 Amherst Rd., Ste. 335 AUTHORIZED REPRESENTATIVE Sunderland MA 01375 CIIIi-.L dhyt- ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD c . pie-o�-a-l�i�,d To Be Titled INVOICE City of Carmel Stock Date Address No. 6/15/2014 3 Civic Square Miles Del. City/State Zip , 35 Date DELIVERED Carmel, IN 46032 serial No. Telephone 571-2417 Home Work Year 2014 Make Ford Model Police Interceptor Type UTILITY Color WHITE Purchase 31938 Federal ID# 35-60000972 Order# Factory Installed Equipment LIEN INFORMATION THE HUNTINGTON NATIONAL BANK 105 EAST 4TH STREET(CNO1) CINCINNATI, OH 45202 Et;C38107 EGC38112 EGC38100 EGC38108 EGC38103 EGC49715 EGC38104 EGC38105 EGC38097 EGC38098 EGC38101 EGC38099 EGC38106 EGC38113 EGC38102 EGC38110 EGC38109 Ea38111 Insurance Co.Name TOTAL $ 481,942.00 Agent's Name Agent's Address Agent's Phone Policy It Trading Difference $ 481,942.00 Year Make Model Color 7%Sales Tax EXEMPT n 2-DR 4-DR Tire Tax I#of tires $ u Delivery Cost Serial No. 1 A/C in Auto 11 Cyls Total Cash Difference $ 481,942.00 Mileage Balance Owed on Used Vehicle $ - Total Balance Due $ 481,942.00 Balance Lein Date Less Cash Rec Owed Holder Unpaid Balance of Cash Price $ 481,942.00 Salesman Aproved `Customer Date by DON HINDS FORD, INC. 12610 Ford Drive Phone (317)849-9000 x1290 Fishers, IN 46038 Toll Free (800)644-4637 x1290 john @donhindsford.com Direct Phone& Fax 317-813-1319