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HomeMy WebLinkAboutCertificate of Liability Insurance ACOR TM CERTIFICATE OF LIABILITY INSURANCE DATE 12/02/2004) PRODUCER (317)814-8244 FAX (317)814-8245 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION United Insurance Agencies ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Indianapolis Branch ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 90 Executive Drive, Suite F Carmel, IN 46032 INSURERS AFFORDING COVERAGE NAIC# INSURED Pedcor Offices, 'IC Building Three INSURER A: United Fire Group One Pedcor Square INSURER B: 770 3rd Avenue S.W. INSURER C: Carmel, IN 48032 INSURER D. INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR•DD' POLICY EFFECTIVE POLICY EXPIRATION 1G -• TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MMIDDNY) LIMITS GENERAL LIABILITY 60323211 05/25/2004 05/25/2005 EACH OCCURRENCE $ 1,000,000 © COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 PRFMISFS(Fa nrcurenre) f ■■ CLAIMS MADE [X I OCCUR MED EXP(Any one person) $ 5,000 A ■ PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY n PROT 1 )- (-1 LOC Ter- AUTOMOBILE LIABILITY 60323211 05/25/2004 05/25/2005 COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO 1,000,000 ALL OWNED AUTOS BODILY INJURY $ A , SCHEDULED AUTOS (Per person) — ® HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ■ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ ■ OCCUR [ CLAIMS MADE AGGREGATE _ $ IN DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- I OTH- EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ It yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER – DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS City of Carmel Indiana is named additional insured for liability coverages CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, City of Carmel Indiana BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY One Civic Square OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Carmel, IN 46032 AUTHORIZED REPRESENTATIVE ' Kurt McKinley/JSE ACORD 25(2001/08) ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) P Av: aTtrP,- SALES DISCLOSURE FORM .,z Stele Form 46021(R419-04) PRIVACY NOTICE: The telephone I IIM II'I� IIII I �OfII III II III ''' �' numbers of the parties on this form are NT II I I I f r Ic Prescribed b Department of Local Government Finance � ��� ;'.ak'� a y P confidential according to IC 6-1.1-5.5- Pursuant to IC 6-1.14.5 3(d). refs W�,,� �r� �"'' zf a.. . ,4sj°=.'��. �c.�' . . �^�c'�°s.s:"r{;y. . ,. n ��� •r <�-„}�s;>.e ., .:�<C.i.. a.a^:�. >. t.,.�::„�.� �N.'Yr*-�r'.�ry- r.. r �� ate,; NII PART j\To be'conmplet CIV''BUYER/GRANTEElanc1 SEL`LER/GRANTOR,(typed)or�irinted'In�bl ca k4ln i) ” � ,:, :fi.-. . Part of Pao Parcel Number(s) (Show additional parcels on separate sheet if necessary.) Acreage or Lot Size (sR JJjJ 9 I- II J1iJ. JJJ `� j jjjjjjjujujljjjjjljjjjjj 0 JJJJJ 0 j jjjjjjjjjljjjjjj]Jjljjjj jul-ui 0 t.„ W' Address k of Parcels Civic Center Drive JJ___I �' .t F°; City,Town,or Post Office State ZIP Code zt Carmel JJ 41_6J012_121 - ]jlj D--4 Tax Billing Address(if other than property address) iOf ai: One Civic Square 0 City,Town,or Post Office State ZIP Code Carmel JJ J l01J.2] - ]jjj ': Legal Description im Identify all conditions/items that apply NOTE: If items 12-21 apply,filers are not subject to disclosure filing fee. O1-Buyer is a " ___ O 12-Security interest documents such as mortgages or trust deeds. la 0 2-Vacant La HAMILTON MILTO N i-Leases less than 90 years 317-843-5300 Fax-843-5429 0 3-Exchange TITLE SECURITY LLC 4-Document resulting from foreclosure,or express O4-Seller Psi neat of foreclosure,divorce court order,condemnation, `"' C `�c.� a-� \ robete or other Judicial proceedings.•Cr)u: Z' gip' O 5-Change r 5-Agreements and other documents for -P p special cart g vergers,consolidations,and incorporations Z ' , O 6-Existent, 6-Quitclaim deeds not serving as a source of title O7-Land Co 17-Documents Involving the partition of land between ti 'manta In common.Joint tenants,or tenants by the ,r',Yr O 8-Personal intlrety. r 18-Transfer to a charity,not-for-profit or government Lnetitutlon ' O 9-Signific, 19-Transfer for no or discounted consideration,or gift O10-Non-Vs ..-,,., „-_ 20-Rerecording to correct prior recorded document 0 11-Partial interest. Describe In special circumstances. O 21-Easements,Right-of-way grants ¢ Contract Date MMIDD/YYYY) Sales Price 1 2 0 8 2 0 0 4 $ p= Describe any unusual or special circumstances related to this sale,including the specification of any less-than-complete ownership interest and terms of seller financing. W cn s INDIANA SALES DISCLOSURE FORM Page 2 37. ldriiI k", t .1 -•" ss,460,-:. `;,"r. j am.:sM, .muds—.,,,,aYtw +,11,74.',.,1,,,A-,,,,,,,.'∎*,c, r.. c. .'1,,4f.ttter A41,1-4--; =e40` .i;3.h l „� r fi }43°0.a., A,-; �;PARTr,1,,To..becompleteclbyBUYER/GRANTEEand,SEER/GRANTOR'(typedl onpnntedAn-blac.k?mkl'~sMpA,I,-,, Ott r* x Seller 1-Name or Entity as appears on deed L Pedcor Office, LLC P. Address kE ',- 770 3rd Ave SW ,N. =,,t3. City,Town,or Post Office State ZIP Code 4 Carmel Jj • 41610]22 - JJJ r ' Seller 2-Name or Entity as appears on deed N Address Rc "o�G ; x;i City,Town.or Post Office State ZIP Code i,,.-..,:.,... JJ JJJJJ j j j j „,,,,,. . Title Company Name(if applicable) Title Company Phone V Hamilton Title Security, LLC J 7] - 1.41___l - JJJ ] r's .. -t "� Buyer 1-Name or Entity as appears on deed „• City of Carmel Redevelopment Commission Will this property be the c. buyer's primary 0,1' Address residence? ''s One Civic Square 0 Yes ®No r N toe) City,Town,or Post Office State ZIP Code c, JJ Jll li JJ JJjJ ro' Carmel r; Buyer 2-Name or Entity as appears on deed w1?moo • �_y Address s : ��,� City,Town,or Post Office State ZIP Code k,:»= JJ JJJJ - JJJ 1 ? ..-.2:,:,; 'Under penalties of perjury,I hereby certify that this Sales Disclosure,to the best of my knowledge and belief,is true,correct and complete as required by law,and Y{- is pre ared in accordant with IC 6-1.1-5.5,"Real Property Sales Disclosure Act". ,', Si slur of / mature of Buyer :w < Seller Sign Date � 2 / '8 / 2 0 0 4 (MM/DD/YYYY) 1 2 / 0 8 2 0 0 4 ,..i.. , •j/ 11 Ors O ...ky, Seller Phone Buyer Phone ]2jJo3Jjjj ±L - ±L - LLJJ iei4:4,PART+2 C OUNTY AUID lip R ,r, :7 ,..'.34A:: ., •_ ',+,r f?ARI.3.-`,•,COUNT.WO,R TQWNSHIF ASSESSQR-*y: A T, .-, `;r,- y County Assessor or other assessing offlcal must verify and complete the following information: OSignificant physical changes to property between March 1 and date of sale AUDITOR'S FILE STAMP $ AV LAND Property class I _Ili use code Taxing DiisWct(DLGF assigned) -$ AVIMPV J!J IJJJ Completion O Yes 0 No Date Entered in Transfer Book AV TOTAL O Valid Sale / / 1 11J 1 1 1 1 L] J 1 NEIGHBORHOOD CODE k I r INDIANA SALES DISCLOSURE FORM Page 2 NI teml ,„. _ ,, . -.PART 1 To loo conmpleteri by HIA ER/ kA IE.E.anrii SFI 1 n:2/GRANTOR ttypr i or ,prii tc,i Itt,Dl ckvnk) : .f42.-.'" -• Seller 1-Name or Entity as appears on deed Pedcor Office, LLC " Address N 770 3rd Ave SW trt City Town,or Post Office State ZIP Cods t'� Carmel l J N 4� 61 0 13_1?, - JJJJ )y Seller 2-Name or Entity as appears on deed - tr Address r f • City.Town,or Post Office State ZIP Code ',� ii JJJJ - 111 T• itle Company Name(If applicable) Title Company Phone 5 1 Hamilton Title Security, LLC J. JJ - 814111 - 51.311111 c "4} }� Buyer 1-Name or Entity as appears on deed t' City of Carmel Redevelopment Commission Will this property be the buyers primary Address 44 [ residence? ;'"ti, One Civic Square 0 Yes le No yv, or$ City,Town,or Post Office State ZIP Coda keel Jj JJJJ - JJJJ �� Carmel 4 6 0 3 2 c? - wt Buyer 2-Name or Entity as appears on deed 'tat.. s7 Address City Town,or Post Office State ZIP Code JJ JJJJJ i ji j I tinder penalties of perjury,I hereby eerily that this Balsa Disclosure,to eta best of my knowledge and belief, ru co ct aI•complete se required by law,and -A is pre•.rod In accordan with IC 0,1.1.6.5,"Real Property Sales Disclosure Act". < S At of xl, A A S r nature of: . I • JJfIVA/ ESQ � j► ,i`i?/� 04N r h S• aar nwonmr) 1 2 / 0 w8 / 2 0 0 4 `�B,o n° `' 'if / 0 8 / 2 0 0 4 sI° • S• eller Phone - ��A - �J�A or ?l - J ] . !1±JOJ PART12;ICOUNIlfrAUDITOWI :. ' i, ,. ' '',:k" PART 37COUNTIY OR'1(5WNsi11,,ASS-LSSpl2. - N,;.' v-,,;,4-:- County Assessor or other assessing offical must verify and complete the following Information: • O Significant physical°hengea to property between March 1 and data of sale e AUDITOR'S FILE STAMP $ , 1 AV LAND I Property class! Jws ouch TeeIng District IDLGF assigned) , , AV IMPV J J JJJ Completion O Yes Q No Date Entered in Transfer Book $ AV TOTAL valid Sale / / I I I HI I I I [J, JNEIOHBORN00000DE