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HomeMy WebLinkAbout2015 Police Schedule 24 pay request 19 092315 Lease 2015 — Sch # 24 (Police Dept.) Payment Request # 19 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 5, 2015 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: Koorsen Security Technology Amount: $2,214.75 Description of Equipment.Item Cost: Security Camera Installation Dated: 09/22/15 LESSEE: City of Carmel One Civic Square Carmel, IN - 032 By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) Make check payable to: Koorsen Security Technology 6121 East 30th Street, Suite A Indianapolis, IN 46219 PAGE I ACCoRCA CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 1/13/2015 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 NAME: Marianne Uban Hylant Group +alc°."N.Exu:317-817 5136 FAX No):317-817-5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADDRESS:marianne.uban @ hylant.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Charter Oak Fire Insurance Co 25615 INSURED CARME80 INSURER B: City of Carmel INSURER C: One Civic Square INSURER 0: Carmel, IN 46032 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:682333440 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 LTR INSR WYE/ POLICY NUMBER (MMIDDIYYYY)1MM1001YYYY) LIMITS A GENERAL LIABILITY Y ZLP14T62033 1/1/2015 1/1/2016 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) $0 PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY 7 PRO- POLICY LOC $ A AUTOMOBILE LIABILITY H8103036P64ACOF15 1/1/2015 1/1/2016 COMBINLD SINGLE LIMIT Ea accident 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 LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN •' ` -R ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE= $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 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& Its Assignors&Assignees ACCORDANCE WITH THE POLICY PROVISIONS. do American Lease Insurance 654 Amherst Rd., Ste. 335 AUTHORIZED REPRESENTATIVE Sunderland MA 01 375 fte �,f1.. �L�i�J,??''--©x(1.•988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2.010105) The ACORD name and logo are registered marks of ACORD KoQr s ego Project Invoice Koorsen Security Technology- Indianapolis, IN SECURITY TECHNOLOGY 6121 East 30th Street, Suite A Indianapolis , IN 46219 REMIT TO: Telephone (317)225-5968 Koorsen Security Technology Fax (317)225-5045 6121 East 30th Street,Suite A Indianapolis,IN 46219 Prepared By: Christie Yoder Please include invoice number on check. Email: Christie.Yoder @KSTSecurity.com Client: City of Carmel Date: 7/7/2015 1 Civic Square Invoice No.: 117657 Carmel, IN 46032-2584 317.571.2576 Client No.: 1686 Order No.: 803966 Order Date: 7/7/2015 Salesperson: Shannon Martindal Client P.O. No.: 32979 Terms: Net 25 days Project Name: Due Date: 8/1/2015 Carmel PD-Axis P3384V Site Address: Carmel Police Dept 3 Civic Square Carmel, IN 46032 (317)571-2531 (317)571-2588 Description Total Original Contract Amount: $ 2,214.75 Amount Billed This Invoice: ioo.00% $ 2,214.75 $2,214.75 Invoice Total: $ 2,214.75 $2,214.75 Koorsen Federal ID#27-2520597 Job Invoice Progress Billing A Service Charge of 1.5%per month(18%annual)will be charged on past due accounts.