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2012 police pay request 12 Lease 2012 Sch #9 (Police Dept.) Payment Request 2012 -12 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: Safety Systems Amount: $6,379.27 Description of Equipment Item Cost: New Vehicle Equipment Dated: June 6, 2012 LESSEE: City of Carmel One Civic Square Carmel, IN 41032 By: Ay Name: Diana Cordray Title: Clerk Treasurer IF (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Safety Systems 4113 Turner Road Richmond, IN 47374 1'AGE 1 ------Th OP ID: 79 A/RO- CERTIFICATE OF LIABILITY INSURANCE DATE 04 /20 DIYYY) 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 OW CT Marianne Uban Hylant Group Inc Indianapolis PHONE FAx 301 Pennsylvania Parkway, #201 317- 817 -5151 (Aq No 317- 817 -5136 I (Ao,Noo). 317- 817 -5151 Indianapolis, IN 46280 E-MAIL marianne.uban @hylant.com W. Michael Wells PRODUCER CARME80 _CUSTOMER ID.N. INSURER(S) AFFORDING COVERAGE 1 NAIC INSURED City of Carmel INSURER A: Travelers Insurance Companies Steve Engelking One Civic Square INSURER B: Carmel, IN 46032 INSURER C: I INSURER D I INSURER E INSURER F I COVERAGES CERTIFICATE NUMBER: 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 1 TYPE OF INSURANCE I IY ADDLSUBRI POLICY EFF7POLICY EXP I LIMITS LTR INSR IWVD POLICY NUMBER (MMIDDYYY) (MMIODIYYVY) GENERAL LIABILITY EACH OCCURRENCE I$ 2,000,000 A -DAMAGE-TO-RENTED GENERAL LIABILITY GP09315757 01/01/12 01/01/13 pREMISES(Eaouvnence) 5 50,000 CLAIMS MADE 1 X I OCCUR MED EXP (Any one person) 0 PERSONAL 8. ADM INJURY 2,000,000 1 GENERAL AGGREGATE 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP AGG 2,000,000 POLICY PI RC)T- LOC Ff AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 2,000,000 A X I ANY AUTO 8103036P64A 01/01/12 01/01/13 (Ea accident) BODILY INJURY (Per person) I ALL OWNED AUTOS BODILY INJURY (Per acddent) SCHEDULED MHOS PROPERTY DAMAGE NON-OWNED UTOS (Per accident) NONOKMED AUTOS UMBRELLA LIAB I OCCUR EACH OCCURRENCE 1 EXCESS LIAB CLAIMS MADE AGGREGATE S DEDUCTIBLE 1 RETENTION WORKERS COMPENSATION I ITORYLI_M VuC STAT IT$ ER U- OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORPARTNERIEXECUTIVE E.L. EACH ACCIDENT OFFICER /MEMBER EXCLUDED? NIA I (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 ATTACHED DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if 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 0� j ,Sunderland, MA 01375 ��/rL� 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD NOTEPAD CARDES9 PAGE 2 INSURED NAME City of Carmel OP ID: 79 DATE 94/20/12 NAMED INSURED: CITY OF CARMEL CARMEL CLAY PARKS BUILDING CORPORATION CARMEL CLAY BOARD OF PARKS S 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 COMM'L ARTICLES: $875,830 W /$1,000 DEDUCTIBLE FINE ARTS: $1,759,975 W /$1,000 DEDUCTIBLE NOTEPAD: HOLDER CODE HUNTI -2 CARME80 PAGE3 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 Lender's Loss Payee Re: Various Police Equipment/Vehicles Safety Systems I1 H V O U© I 4113 Turner Road Richmond, IN 47374 Invoice Number: 1252917 Invoice Date: May 29, 2012 Page: 1 Voice: 765 935 -3566 Duplicate Fax: 765- 935 -9713 BiIIrro Ship to: Carmel Police Department 3 Civic Square ATTN: Teresa Anderson Carmel, IN 46032 Customer ID Customer PO Payment Terms Carmel P.D. 26113 Net 30 Days Sales Rep ID Shipping Method Ship Date Due Date' Hand Deliver 6/28/12 Quantity Item Description Unit Price Amount 3.00 PKG- CON -114 358.09 1,074.27 10.00 C -TCB -7 -IMP 81.50 815.00 10.00 C- 3090 -3 114.50 1,145.00 3.00 IM13UFZ Inner Edge -12 Tahoe 803.96 2,411.88 4.00 Whelen Dominator D2RR 116.64 466.56 4.00 Whelen Dominator D2BB 116.64 466.56 Subtotal 6,379.27 Sales Tax Total Invoice Amount 6,379.27 Check /Credit Memo No: Payment/Credit Applied TOTAL 6,379.27