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Home My WebLink About2015 Police Schedule 24 pay request 20 100615 Lease 2015 — Sch # 24 (Police Dept.) Payment Request # 20 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: L3 Mobile-Vision, Inc Amount: $1,414.00 Description of Equipment Item Cost: In car camera equipment Dated: 10/05/15 LESSEE: City of Carmel One Civic Square Carmel,IN -6032 J By: dj Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) Make check payable to: L3 Mobile-Vision,Inc PO Box 5580 New York,NY 10087-5580 PAGE 1 �, . Invoice communications Mobile-Vision, Inc. Invoice Number: 0230763-IN 90 Fanny Road Invoice Date: 9/25/2015 Boonton, NJ 07005 Phone: (800) 336-8475 Order Number: 0143855 Fax: (973) 257-3024 Salesppee orsrson: ZLMBDate 9/18/2015 LMB Customer Number: INCARME Tracking Number: 1zx5x9890367232582; Sold To: Ship To: Carmel Police Department Carmel Police Department 3 Civic Square 3 Civic Square Attn:Brian Smith Attn:Brian Smith Carmel,IN 46032 Carmel, IN 46032 Confirm To: Brian Smith Page: 1 Customer P.O. Ship VIA F.O.B. Terms 33164 UPS GROUND BOONTON,NJ Net 30 Days Item Number Unit Ordered Shipped Back Order Price Amount VLXFA EACH 2.00 2.00 0.00 455.00 910.00 VLX Kit-includes wireless mic, In-Car base. Include panavise mount and lapel mics.Does r Whse: 000 SNI FB217342-FB217343 MVD-MC-ASSY EACH 1.00 1.00 0.00 395.00 395.00 Console Assy,monitor,FB Whse: 000 SN:FB134668 MV-ICV-EMIC EACH 2.00 2.00 0.00 45.00 90.00 Microphone,backseat,HD,Sys7,15'cable Whse: 000 PLEASE REMIT PAYMENT TO L-3 COM MOBILE-VISION, INC Subtotal: 1,395.00 PO BOX 5580 NEW YORK,NY 10087-5580 Ship/Handling: 19.00 Sales Tax: 0.00 Invoice Total: 1,414.00 These commodities are controlled under the Export Administration Regulations(EAR)and may not be exported without proper authorization by the US Dept of Commerce. A CERTIFICATE OF LIABILITY INSURANCE DATE DnrvY) 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 CONTACTNAME: Marianne Uban Hylant Group CNIA/ o,Exu;317-817-5136 (A/C,No):317-817-5151 301 Pennsylvania Parkway,#201 DRl Indianapolis IN 46280 ness:marianne.uban 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 D: 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 LTR TYPE OF INSURANCE INSR DDL SUBR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DDIYYYY) (MM/DD/YYYY) 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 dECDT LOC $ A AUTOMOBILE LIABILITY H8103036P64ACOF15 1/1/2015 1/1/2016 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 LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 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/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 ML �,/)� IDS-�t� ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD