HomeMy WebLinkAbout318583 11/15/2017 ���`' CITY OF CARMEL, INDIANA VENDOR: 00352999
ONE CIVIC SQUARE HYLANT GROUP
`� CHECK AMOUNT: S""""'712.38"
�3 �q CARMEL, INDIANA 46032 PO BOX 638720 CHECK NUMBER: 318583
�y,-roN�, CINCINNATI OH 45263-8720 CHECK DATE: 11/15/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347500 159288 712.38 GENERAL INSURANCE
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IFIG Policy Number 2776511605
Companies COMMON POLICY DECLARATIONS
Renewal of:
THE BURLINGTON INSURANCE COMPANY
Home Office:Burlington, North Carolina
Administrative Office: 238 International Road,Burlington,NC 27215 Claims Office:238 International Road,Burlington,NC 27215
Item 1. Named Insured and Mailing Address Co.Use:
Carmel Porchfest Inc Burns&Wilcox,Ltd.
8888 Keystone Crossing
Ste 710
Indianapolis
IN 46240
Mail Addr: 14529 Norwalk Dr Code: 0277
CARMEL Surplus Lines Broker License No.:980028
IN 46033
Itern 2. Policy Period Effective Date:09/16/2017 Expiration Date: 09/17/2017
at 12:01 A.M. . StpndpCd Time at XQur mailing address shown above.
Item 3. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to
provide the insurance as stated in this policy. This policy consists of the following coverage parts for which a
premium is indicated. Where no premium is shown,there is no coverage.
Coverage Parts Premium
COMMERCIAL GENERAL LIABILITY $ 655.00
$
$
Total Policy Premium or Deposit Premium $ 655.00
Other Charges(if applicable) Total Other Charges $ 57.38
Policy Fee 40.00 g
Surplus Lines Tax 17'38 Total Amount Due- $ 712.38
Premium is: ®Flat ❑Auditable Policy Minimum Premium $ 655.00
In the event you cancel this poligy, we will retain Minimum earned premium, See form BG-i-026
Item 4. Forms and Endorsements applicable to this policy: See"Listing of Forms and Endorsements"(IFG-1-0150)
Item 5. Form of Business. ❑Individual ❑ Partnership ❑ Joint Venture
❑Limited Liability Company ® Other Organization, including a Corporation
❑Trust Corporation
Business Description: Family friendly music festival.live music on 20 area porches
THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE FORM(S)AND ANY
ENDORSEMENT(S),COMPLETE THE ABOVE NUMBERED POLICY.
Countersigned: 09/11/2017 By: Burns&Wilcox, Ltd.
IFG-1-0101 04 14 Date Authorized Representative Page 1 of 1
hsrn# Trans Eff Deb Due Date Trans Description Amount
General Liability Policy# 27713511605 Effective: 9/16/17 - 9/17/17
Issuing Company Burlington Insurance Company
1209639 9/16/2017 9/18/2017 RENB 2017 Carmel Porchfest General Liability 655.00
1209640 9/16/2017 9/18/2017 CTAX Surplus Lines Tax 17.38
1209641 9/16/2017 9/18/2017 CFEE Policy fee 40.00
Total Invoice Balance: $712.38
svba 7;
NOV 14 2017
Clerk 1reasurer
HYLANT Hylant-Indianapolis 10401 North Meridian St,Ste 200 Indianapolis IN 46290
9/11/2017 Carmel Porch Fest,Inc. Loan# Invoice#159288 FARWEI Page 1 of 1