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2015 Police Schedule 24 pay request 2 041315 Lease 2015 — Sch # 24 (Police Dept.) Payment Request # 2 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 alllof 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: Safety Systems Amount: $3,812.36 Description of Equipment Item Cost: Safety Equipment for new vehicles Dated: 04/10/2015 LESSEE: City of Carmel One Civic Square Carmel,IN $032, d, t f / a j •, By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statem, t) PLEASE PAY VIA WIRE TRANSFER: 9d) )\( PAGE 1 Safety Systems 4113 Turner Road Richmond, IN 47374 Invoice Number: 15032512 Invoice Date: Mar 25, 2015 Page: 1 Voice: 765-935-3566 Original Fax: 765-935-9713 A,, .... . ' �. :.,. ra.;s, '. Shi'Ato 3 �„, tiro r.,•iY.i rye'w. - „'is 6 a r: Brll To '� ; ny+�q�x„� � , b,„ti+ �, x p` ,, ..A ,y�F`Y�m.°fr mss, ro.a",�, Ra asg^.v, �� . .. ,. Carmel Police Department Carmel Police Department 3 Civic Square 3 Civic Square ATTN: Pat Young ATTN: Pat Young Carmel, IN 46032 Carmel, IN 46032 p ', Customer ID F a a Custori er PO '” � . , '� Payment Carmel P.D. 32264 Net 30 Days ., a Sales Rep IDs Y^ ""5 " Shipping'KMetho l c Hand Deliver 4/24/15 ;,,� �Quantrty ttem << :w Description° Unit Pr ce Amount 4.00 Slicktop/ unmarked package 2,140.38 8,561.52 10.00 Integrity package 2,170.00 21,700.00 13.00 Whelen TIR3- Red 46.00 598.00 13.00 Whelen TIR3- Blue 46.00 598.00 80.00 Whelen Vertex LED White 55.50 4,440.00 V‘f\ Subtotal 35,897.52 Sales Tax Total Invoice Amount 35,897.52 Check/Credit Memo No: Payment/Credit Applied X35,89752 AC R CERTIFICATE OF LIABILITY INSURANCE 1/13/2015 DATE DPI 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 IA/C.I o.eeu:317-817-5136 FAX (,i .,1% ):317-817-5151 301 Pennsylvania Parkway,#201 -RIndianapolis IN 46280 aDess:marianne.uban h lant,corn INSURER(S)AFFORDING COVERAGE NAIC fJ INSURER A:Charter Oak Fire Ins�lrn_ce__o 2_5615 INSURED CARM E80 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 TYPE OF INSURANCE INSR SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR I M M!D DIYYYY I I M M!D DlYY1'Y J A GENERAL LIABILITY Y ZLP14T62033 1/1/2015 1/1/2016 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 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 GE 'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OR AGG $2,000,000 POLICY PRO- JECT 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- R AND EMPLOYERS'LIABILITY Y!N TO'V It, ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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. c/o American Lease Insurance 654 Amherst Rd., Ste. 335 AUTHORIZED REPRESENTATIVE Sunderland MA 01375 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD