2012 Police Pay request 2 Lease 2012 Sch #9 (Police Dept.)
Payment Request 2012 -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 March 8, 2012 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: Laser Technology, Inc.
Amount: $7,789.00
Description of Equipment Item Cost:
Accident Mapping Laser and Accessories
Dated: April 26, 2012
LESSEE:
City of Carmel
One Civic Square
Carmel, IN 46032
Name: Diana Cordray
Title: Clerk Treasurer
(Attached duplicate original of Payee's statement)
PLEASE MAIL CHECK TO: Laser Technology, Inc.
Key Bank
P.O. Box 1068
Englewood, CO 80150-1068
PAGE 1
�1---.11 OP ID: 79
A CERTIFICATE OF LIABILITY INSURANCE DATE 04/2
04/20/1 2
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 800- 678 -0361 NAME: Marianne Uban
Hylant Group Inc Indianapolis 3 17- 817 -5151 PONE 317- 817 -5 FAX 317 817 -5151
301 Pennsylvania Parkway, #201 (A No.Extl: 136 1 Ne
Indianapolis, IN 46280 E -MAIL
ianne.ubanh lant.com
W. Michael Wells ADDRESS: m ar �:.Y
PRODUCER CARME80
CUSTOMER It k#:
INSURER(S) AFFORDING COVERAGE NAIC
INSURED City of Carmel INSURER A: Travelers Insurance Companies
Steve Engelking
One Civic Square INSURER 9:
Carmel, IN 46032 INSURER C:
INSURER 0
INSURER E
INSURER F I
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 15 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 I5 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. 1 LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR 1 TYPE OF INSURANCE 'NCR LIAND POLICY NUMBER (MMD I/MMDDIYYYY) I LIMITS ADDL
GENERAL LIABILITY EACH OCCURRENCE 5 2,000,000
A COMMERCNL GENERAL LIABILITY DAMAZ3ETCRENTED
GP09315757 01/01/12 81/01/13 PREMISES (Ea ocmnence) 50,000
CLAIMS -MADE X OCCUR MED EXP (Any one person) 0
C PERSONAL E. ADV INJURY 5 2,000,000
GENERAL AGGREGATE 5 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP AGG 2,000,000
1 POLICY 1 I PR° nI LOC
I AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIMIT 2,000,000
I (Ea awdent)
A 110 ANY AUTO 8103036P64A 01/01/12 01/01/13 BODILY INJURY (Per person)
ALL OWNED AUTOS BODILY INJURY (Per accident)
SCHEDULED AUTOS
PROPERTY DAMAGE
HIRED AUTOS (Per accident)
NON -0WNED AUTOS 5
I$
UMBRELLA LIAR OCCUR EACH OCCURRENCE 5
EXCESS LIAO CLAIMS -MADE AGGREGATE 5
DEDUCTIBLE 5
RETENTION 1
WORKERS COMPENSATION 1 VAC STATU- 10TH-I
Y N
AND EMPLOYERS' LIABILITY TORY LIMITS I �-ER_,
ANY P ROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT I
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory In NH) E.L. DISEASE EA EMPLOYEE
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE POLICY LIMIT I
A PROPERTY i 630581M4076 01/01/12 01/01/13 SEE
EEACHED
DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (Attach ACORD 101, Additional Remarks Schedule, 0 more space is required)
SEE ATTACHED.
CERTIFICATE HOLDER CANCELLATION
HUNTI -2
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The Huntington National Bank ACCORDANCE WITH THE POLICY PROVISIONS.
its assignors and assignees
C/O American Lease Insurance AUTHORIZED REPRESENTATIVE
654 Amherst Rd. Ste 335 L
t u4-fC>
Sunderland, MA 01375
1988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
CARME80 PAGE 2
NOTEPAD
INSURED'S NAME City of Carmel OP ID: 79 DATE 04/20/12
NAMED INSURED:
CITY OF CARMEL
CARMEL CLAY PARKS BUILDING CORPORATION
CARMEL CLAY BOARD OF PARKS RECREATION
CARMEL REDEVELOPMENT COMMISSION
CARMEL REDEVELOPMENT AUTHORITY
CARMEL CITY CENTER COMMUNITY DEVELOPMENT CORPORATION
PROPERTY LIMITS:
BLANKET BUILDING.AND BUSINESS PERSONAL PROPERTY: $360,243,099
REPLACE COST, AGREED VALUE
SPECIFIC BUILDING LIMIT: $2,623,959 SPECIFIC BUSINESS PERSONAL PROPERTY
LIMIT: $150,000
BLANKET BUSINESS INCOME/EXTRA EXPENSE /RENTAL VALUE: $5,000,000
ACTUAL CASH VALUE, AGREED VALUE
SPECIAL CAUSE OF LOSS FORM
EQUIPMENT BREAKDOWN- INCLUDED
DEDUCTIBLE: $25,000
FLOOD LIMIT: $10,000,000 W /$50,000 DEDUCTIBLE
EQ LIMIT: $10,000,000 W /$50,000 DEDUCTIBLE
CONTRACTORS EQUIPMENT LIMIT: $2,9,47,385 W /$1,000 DEDUCTIBLE
CONTRACTORS LEASED EQUIPMENT: $100,000 W /$1,000 DEDUCTIBLE
MISC. SCHEDULED EQUIPMENT: $2,732,599 W /$1,000 DEDUCTIBLE
EDP LIMIT: $880,591 W /$1,000 DEDUCTIBLE
COI4]'L ARTICLES: $875,830 W /$1,000 DEDUCTIBLE
FINE ARTS: $1,759,975 W /$1,000 DEDUCTIBLE
NOTEPAD: HOLDER CODE HUNTI -2 CARME80 PAGES
INSURED'S NAME City of Carmel OP ID: 79 DATE 04/20/12
The Huntington National Bank and its Assignors and Assignees, ATIMA are
named as Lenders Loss Payee Re: Various Police EquipmentNehicles
LI /ERs Laser Technology, Inc. Page Number
TECI- MOLOGY INVOICE Date 4/26/2012
ORIGINAL Customer 78529
7070 S. TUCSON WAY
CENTENNIAL, COLORADO 80112 Brn /Plt 10
TEL. (303) 649 -1000
FAX: (303) 649 -9710 Related P.O.
Order Nbr 67717 TD
Sold To: CARMEL POLICE DEPARTMENT Ship To: CARMEL POLICE DEPARTMENT
Invoice 125419 RI
3 Civic Square 3 Civic Square
ATTN: TERESA ANDERSON CARMEL IN 46032
CARMEL IN 46032
Attention: Attention:
Description
Certificate
Request Date Customer P.O. F.O.B. Delivery Instructions UPS GROUND
5/9/2012 26141 FOB ORIGIN
LT AMY STEIN 317.571.2500
Ln/Rq Dt Description Item Number UM Ship /Back/Cancel Price Extended Price Tax
Any questions pertaining to this order? Please call 303.649.1000 x157
1.000 RECON 400X,W /0 BLUETOOTH 3255018 EA S 1 999.00 999.00 Y
2.000 ASSY,YOKE MOUNT,RIGHT,IMPULSE 7024835 EA S 1 57.00 57.00 Y
3.000 Cradle Assy,Recon 3504643 EA 5 1 89.00 89.00 Y
4.000 Plumb Bob,l2oz (340 grams) 3004667 EA S 1 15.00 15.00 Y
5.000 Bag,Tripod /Prism Sherpa,QMII 3123473 EA S 1 89.00 89.00 Y
6.000 Pole Bracket Assembly,AE 3504631 EA 5 1 79.00 79.00 Y
7.000 Tripod,Instrument,Aluminum,BLK 3504630 EA S 1 184.00 184:00' Y
8.000 Tribrach,Black 3003255 EA S 1 199.00 199.00 Y
9.000 OUICKMAP 3D V5.0 SOFTWARE PKG 7035066 EA S 1 495.00 495.00 Y
10.000 Fixed Tribach Adapter 3004670 EA 5 1 47.00 47.00 Y
11.000 KIT,TRUANGLE 7006000 EA 5 1 995.00 995.00 Y
11.010 ASSY,FINAL,TRUANGLE(LCAE) 7024832 EA S 1 .00 Y
TA000223
11.020 BOX W /FOAM, TRUANGLE 3124673 EA 5 1 .00 Y
11.030 Warranty Information 0144699 EA 5 1 .00 Y
11.040 CABLE,INTERFACE,4704,RT,221N 4824163 EA S 1 .00 Y
11.050 Assy Cable,36 ",Turck to DB9, 7053038 EA 5 1 .00 Y
11.060 Non -Stock 0144848 EA 5 .00 Y
11.070 CD,MANUAL,TRUANGLE,W /PAPER SLV 0144849 EA S 1 .00 Y
11.080 ASSY,SIDEBRACKET,SHORT,LCAE 7024833 EA S 2 .00 Y
12.000 Impulse LR 200 7003383 EA S 1 2,795.00 2,795.00 Y
I14503
13.000 TRAINING 3014653 EA S 1 1,200.00 1,200.00 Y
14.000 POWERBOOT, AA, MODULE 3255004 EA S 1 100.00 100.00 Y
15.000 Assy Cable,36'Turck to DB9,Rmt 7054223 EA S 1 101.00 101.00 Y
REMIT TO: FOR PAYMENTS MADE BY WIRE TRANSFER REMIT TO:
LASER TECHNOLOGY, INC. DOMESTIC WIRE TRANSFERS OR EFT'S: INTERNATIONAL WIRE TRANSFERS OR EFT'S:
KEY BANK LASER TECHNOLOGY, INC. LASER TECHNOLOGY, INC.
P.O. BOX 1068 ACCT 769681004370 ACCT 769681004370
ENGLEWOOD, CO 80150 -1068 ABA 307070267 KEY BANK, N.A. KEYBANK SWIFT CODE: KEYBUS33
LACER Laser Technology, Inc. Page Number 2
TECHf1OLOGY INVOICE Date 4/26/2012
ORIGINAL Customer 78529
7070 S. TUCSON WAY
CENTENNIAL, COLORADO 80112 Brn /PII 10
TEL. (303) 649 -1000
FAX: (303) 649 -9710 Related P.O.
Order Nbr 67717 TD
Sold To: CARMEL POLICE DEPARTMENT Ship To: CARMEL POLICE DEPARTMENT
Invoice 125419 RI
3 Civic Square 3 Civic Square
ATTN: TERESA ANDERSON CARMEL IN 46032
CARMEL IN 46032
Attention: Attention:
Description
Certificate
Request Date Customer P.O. F.O.B. Delivery Instructions UPS GROUND
5/9/2012 26141 FOB ORIGIN LT AMY STEIN 317.5711500
Lr'Rq Dt Description Item Number UM Ship /Back/Cancel Price Extended Price Tax
16.000 Case,Angle Encoder /Impulse 3124649 EA S 1 289.00 289.00 Y
17.000 Freight F EA S 1 56.00 56.00 N
Sales Tax Total Order
Net Due Date 5/26/2012 Tax Rate 0 7,789.00
Terms NET 30 (Override)
REMIT TO: FOR PAYMENTS MADE BY WIRE TRANSFER REMIT TO:
LASER TECHNOLOGY, INC. DOMESTIC WIRE TRANSFERS OR EFT'S: INTERNATIONAL WIRE TRANSFERS OR EFT'S:
KEY BANK LASER TECHNOLOGY, INC. LASER TECHNOLOGY, INC.
P.O. BOX 1068 ACCT 769681004370 ACCT 769681004370
ENGLEWOOD, CO 80150 -1068 ABA 307070267 KEY BANK, N.A. KEYBANK SWIFT CODE: KEYBUS33