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2012 Police pay request 15Lease 2012 — Sch #9 (Police Dept.) Payment Request # 2012 -15 EX H [ 131'1' 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 ordcror contract with respect to the Equipment described below and has not formed the basis of any prior request for payment, En addition, the undersigned acknowledges delivery-, installation and receipt in good condition, and hereby accepts the Equipment described on the attached invoices. Payee: Hod ba Instruments inc. Amount: 514,350.00 Description of Equipment Item Cost.: SceneScopc Advance RUVIS System Dated: July 13, 2012 LESSEE: City of Carmel One Civic Square Carmel., IN 461132 Bv: Name: li tan. Title: Clerkdl'r AA:0466? g (Attached duplicate original of Payee's statement) PLEASE MAIL C] -[ECK TO: ]- [oriba Instruments Inc. Lockbox #776013 6013 Solutions Center Chicago, IL 60677 -6000 PAOE1 Ae- -R° CERTIFICATE OF LIABILITY INSURANCE OP ID: 79 DATE I MMIDOPYYYYI 04/20112 THIS CERTIFICATE 15 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 INSURERISI, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policyliesl must be endorsed. If SUBROGATION IS WAIVED, Subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement an this certificate does not confer rights to iho certificate holder in lieu of such endorsement(s). PRODUCER Hylant Group Inc- Indianapolis 301 Pennsylvania Parkway, 4201 Indianapolis, IN 46280 W. Michael Wells INSURED 800 - 678 -0361 317-817-5151 CONTACT : Marianne Uban ,laic° °,Nei . EFn: 317- 817 -5136 1 FAX Nol: 317 - 8175151 City of Carmel % Steve Engelking One Civic Square Carmel, IN 46032 E ADDRESS: marianne.uban@hylant.com PRODUCER CARME80 CUSTOMER ID a. INSURER) AFFORDING COVERAGE INSURER A: Travelers Insurance Companies NAIC V INSURER 5 : INSURER C: INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES INDICATED. NOTWITHSTANDING ANY REOUIREMENT, CERTIFICATE MAY BE ISSUED OR MAY EXCLUSIONS AND CONDITIONS OF SUCH OF INSURANCE PERTAIN, POLICIES. 1 ADDS-SUER AUTHORIZED REPRESENTATIVE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INTSRR TYPE OF INSURANCE POLICY NUMBER [MMIDBIYDI MIDDYEFr POLICYEi { POLICYEXP LIMITS A GENERAL I X LIABILITY COMMERCIAL GENERALLIA6ILI 7 CLAIMS -MADE I 1 X I OCCUR GP09315757 01101112 01101/13 EACH OCCURRENCE 15 2,000,000 DAMAGETO'RENTEU PREMISES [Ea dcwrrance} s 50.000 y 0 MEDEXP (Any one perSOR) GE PERSONAL 8AOVINJURY $ 2,000,000 GENERAL AGGREGATE 1 t 2,900,000 IL AGGREGATE LIMIT APPLIES PER: POLICY I I JFPF in WC PRODUCTS -COMROPAGG 1 $ 2,000,000 5 A AUTOMOBILE X LIABILITY ANY AUTO ALL OARED AUTOS SCHEDULIiDAUTOS HIRED AUTOS NON.CAT'ED AU l OS 8103036P64A 01/01/12 01(01113 COMBINED SINGLE LIMIT (Ea acouenp S 2,000,000 BODILY IN J URY(Per person) EcD 5 UpUILV INJURY (Per a:adent) $ PROPERTY DAMAGE (Per acdp een 5 I UMBRELLA BAD 1 EXCESS LIAR CLAIMS.MADE EACH OCCURRENCE 5 AGGREGATE 5 DEDUCTIBLE RETENTION $ 3 5 WORKERS COMPENSATION ANDEMPLOYERS'LIABIUTY YIN ANY PROPNIETORPARTNERIEYECUTIVE n OFFICER /MEMBER ExCLUDEDi (Mandatory In NHI If yes, deseihe under DESCR,PTIOH OF OPERATIONS below NIA WC STATU• OTH- (CORY' LIMITS I ER E.L EACH ACCIDENT 5 E.L DISEASE - EA EMPLOYEE $ E.L DSEASE- POLICY LIMIT 5 A PROPERTY 630581M4076 01(01/12 01/01113 SEE ATTACHED DESCRIPTION OF OPERATIONS !LOCATIONS ■ VEHICLES (ALUM, ACORD 101, Addiik nal Rumalks Schedule, If more space is required) SEE ATTACHED. CERTIFICATE HOLDER CANCELLATION HUNTI -2 The Huntington National Bank & its assignors and assignees CIO American Lease insurance 654 Amherst Rd. Ste 335 (Sunderland, MA 01375 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE / / / ) ��'uSiC� ACORD 25 (2009/09) © 1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NOTEPAD INSUREDS NAME City of Carmel CARME80 OP ID: 79 PAGE 2 DATE 04120112 NAMED INSURED: CITY OF CARMEL CARMEL CLAY HARKS 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 wsuneD•s NAME City of Carmel CARMEN PAGE 3 OP ID: 79 DATE 04120112 The Huntington National Bank and its Assignors and Assignees, ATIMA are named as Lender's Loss Payee Re: Various Police Equipment/Vehicles HORIBA •Sc ien titic- : iso -soot HORIBA INSTRUMENTS INCORPORATED 3880 Park Ave Edison, NJ USA 08820 -3012 Phone: (732) 494 -8660, Fax: (732) 549 -5125 www.HORIBA.corn/Scientific Bill To: 29379 CARMEL POLICE DEPARTMENT ATTN:TERESA ANDERSON 3 CIVIC SQUARE CARMEL IN 46032 -2584 'i. Ship To`, "29379 ..CARMELLF ATTN. POLICE:.; DEPT TEL: 317 -571 2559 3- .CIVIC CARMEL, IN 546032 -2584 1 INVOICE --> REMIT TO: z;1 Lockbox # 776013 .1 6013 Solutions .Center . <'d. Chicago. IL 6067;7 6000 Information Invoice Number Invoice Date Purchase Order No. Purchase Order Dare Sales Order Number Pocking List Number Shipping Terms Actual Ship Date Payment Terms Duo Date Currency Sales Office #Ppge 1a4 1 90391613 06/29/2012 26191 06/15/2012 219890 80306795 FOB ORIGIN 06/29/2012 WITHIN 30 DAYS DUE NET 07/29/2012 USD JY- Forensics Sales ,InvoiceaDetails" Item Material Description Quantity Unit Price Amount 10 SC- VIEWER -AD SCENESCOPE UV IMAGER GSA Discount S Net Value for Item PURCHASE ORDER NUMBER 26191 MUST APPEAR ON INVOICES, A/P VOUCHER, DELIVERY MEMO, PACKING SLIPS, SHIPPING CABLES AND ANY CORRESPONDENCE DOCUMENT CONTROL NO. 26791 PLEASE INVOICE IN DUPLICATE 1 EA 16,750.00 2,400.00- 14, 350.00 Total Amount.... 16,750.00 2,400.00- 14, 350.00 $ 14,350.00 .. WE4CERTIFYtTHAT THESE GOODS WERE PRODUCED IN COMPUANCE WITH ALL APPLICABLE REQUIREMENTS OF SEC 6 7 ANO 12 OF THE FAIR LABOR ;:,' STANDARDS ACT AS AMENDED, AND OF REGULATIONS AND ORDERS OF THE U.S/DEPARTMENT OF. LABOR ISSUED UNDER SEC 19 THEREOF