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2012 police pay request 13 Lease 2012 Sch #9 (Police Dept.) Payment Request 2012 -13 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: Truck Vault Amount: $5,047.09 Description of Equipment Item Cost: New Vehicle Equipment Dated: June 6, 2012 LESSEE: City of Carmel One Civic Square Carmel, IN 46032 1) 13y: �&Jt J/ C Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Truck Vault P.O. Box 734 Sedro-Woolley, WA 98284 -0734 PAGE 1 OP ID: 79 AC CERTIFICATE OF LIABILITY INSURANCE DATE 04 /20/412011 02 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 CONTACT Marianne Uban Hylant Group Inc Indianapolis PH ONE FAX 301 Pennsylvania Parkway, #201 317 817 5151 (AIO NE E 317 817 5136 (A/C No): 317 817 5151 Indianapolis, IN 46280 E-MAIL W. Michael Wells ADDRESS: marianne.uban @hylant.com PRODUCER CUSTOMER I:CARME80 D. p. INSURER(S) AFFORDING COVERAGE NAIC INSURED City of Carmel INSURER A: Travelers Insurance Companies Steve Engelking One Civic Square INSURER B: Carmel, IN 46032 INSURER C: INSURER D: INSURER E INSURER F 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 !S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE I ADDLSUBR POLICYEFF POLICY LTR INSR Iyy,D I POLICY NUMBER IIMMIDD/YYYY) IIMMIDD/YYYY) LIMITS I GENERAL LIABILITY EACH OCCURRENCE 2,000,000 A X COMMERCIAL GENERAL LIABILITY GP09315757 01/01/12 01/01/13 DAMAGETORENTED 50,000 PREMISESOEa occurrence) CLAIMS -MADE I X OCCUR MED EXP (Any one person) 0 PERSONAL B PDV INJURY 2,000,000 GENERAL AGGREGATE 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP /OP AGG 2,000,000 1 PRO- POLICY ?Pi I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 2,000,000 A 1 X ANY AUTO 8103036P64A 01/01/12 01/01/13 (Ea accident) BODILY INJURY (Per person) ALL OWNED AUTOS BODILY INJURY (Per accident) SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) NON-OWNED AUTOS UMBRELLA LIAR I OCCUR EACH OCCURRENCE I EXCESS LIAB CLAIMS -MADE AGGREGATE DEDUCTIBLE I RETENTION WORKERS COMPENSATION VsC STATU- PA- AND EMPLOYERS' LIABILITY YI N TOR�'LIMIT$ ER ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACHACCIDENT OFFICER /MEMBER EXCLUDED? N A (Mandatory In NH) E L DISEASE EA EMPLOYEE If yes describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE POLCY LIMIT I A PROPERTY 630581M4076 01/01/12 01/01/13 SEE EEACHED 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 j l sr4C¢ /GEC d- Cl ,Sunderland, MA 01375 ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD NOTEPAD CARME80 PAGE 2 INSURED'S NAME City of Ca rmel OP ID: 79 DATE 04/20/12 NAMED INSURED: CITY OF CARMEL CARMEL CLAY PARKS BUILDING CORPORATION CARMEL CLAY BOARD OF PARKS 6 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 PAGE 3 INSURED'S NAME City of Carmel OP ID: 79 DATE 04/20/12 The Huntington National Bank and its Assignors and Assigneeess, ATIMA are named as Lender's Loss Payee Re: Various Police Equipment/Vehicles i RUCK VQ� GSA Invoice P. O. Box 734 Sedro Woolley, WA 98284 -0734 Invoice Number: 112928 Telephone (360) 855.0464 US Toll Free (800) 967.8107 Invoice Date: 05/30/12 Facsimile (360) 855.0834 GSA Contract GS- 07F -0032J Invoice Due Date 06/29/12 Bill To: Ship To: Carmel Police Department IN Carmel Police Department IN 3 Civic Square Attn Brady Myers 3 Civic Square Carmel IN 46032- Carmel IN 46032 USA Customer ID Customer PO Special Instructions Invoice Terms CAR0119 26158 Net 30 Days Sales Order No. j Ship Date Ship Via Account Rep 112928 05/22/12 Conway JS 1 Qty Stock Serial Description Unit Price Extension 3 T CHTAHM1 12N Tahoe Mag 1 Dwr 1,965.00 5,895.00 427550 427551 427552 3 zVault Options -35327 0.00 0.00 Package Special Magnum Height TruckVault 1 Drawer Vehicle Year 2012 No Third Row Seat Exterior Carpet Black Drawer Interior Carpet Black Drawer Front(s) Black Composite 1 Dwr Push Button Lock w /Key Override 3 Long Std Dividers No Residential Delivery 3 zDivider Kit -03596 TruckVault Divider Kit 90.00 270.00 Divider Carpet Gray No Long Dividers Products will be exported from the United States in accordance with the Export Administration Regulations. Diversion or use contrary to U.S. law is prohibited. Gross Amount 6,165 00 GSA Discount 1,692.91 Sub -Total 4,472.09 Shipping and Handling 575.00 Sales Tax 0.00 ACCOUNT IS CONSIDERED DELINQUENT 1 DAY PAST THE DUE DATE. THE FINANCE CHARGE IS 1 5% (18% PER ANNUM). ALLARS TRANSACTIONS TO BE COMPLETED IN US Total Order 5,047.09