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Fire schedule 10 pay request 1Lease 2012 — Sch # 10 (Fire Dept.) Payment Request # 1 EXI I]BIT 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 June 15, 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 alllol'a portion) of the Acquisition Costs descrihed below. The amount shown below is due and payable under a purchase order or contract with respect to the Equipment descrihed below and has not formed the basis of any prior request for payment. In addition, the undersigned acknowItdges delivery, installation and receipt in good condition, and hereby accepts the Equipment descrihed on the attached invoices. Payee: Donley Safety Amount: `5366.590.00 Description of Equipment [tem Cost: 2 Horton 623 -1 WT Ambulance and Equipment. Cost per Ambulance in $ 1 83,295.00 fora total of $365.590.00 Dated: October 1, 2012 LESSEE: City of Carmel One Civic Square Carmel, IN 46032 P By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original -af_Pa ees statement) ['LEASE PAY V1/ WIRE TRANSFER.: (n sfrf.chcT i s G 7d PAGk 1 SAFETY Please Vlstr as on the Web at www.tlonleysarery.com 5548 Elmwood CI. Indianapolis, IN 46203 Phone 317.7fe 2288 Fag 3l11e6.n31 Bill To CARMEL, CITY OF ONE. CIVIC SQUARE CARMEL_ IN 46032 Invoice Date Invoice # 10/1/2012 35322 Service Info CARMEL, CITY OF 2 CIVIC SQUARE CARMEL, IN 16032 S.O. No. Terms Rep Vehicle Mileage VIN Customer P.O. NET 30 IP Item Quantity Description Rate UOM Amount AMBULANCE 2 NORTON 623 -1 -WT AMBULANCE AND EQUIPMENT VIN I FDUF4CT9CEC39654 VIN I FDIJFIGTOCEC39655 183.295_00 366,590.107 Sales Tax (7.O %) $o ou Total $3 (,6,590.00 PRICE DISCREPANCIES, RETURN REQUESTS OR SNIPU6'N1- FRRQRS ml 1ST RE REPORTED WITHIN 30 ]RAYS TO RECEIVE CREDIT_ 11' you huge questions [hoot this invoice, Please call 1)tlhra ()Bair V 317- 786 -2266 oremnil to dodoir@donleysateiy corn Please visit us on the web at www,donleysafety.corn 5546 Elmwood Ct. Indianapolis, IN 46203 Phone 317 - 786 -2268 Fax 317-786-2532 DIRECT DEPOSIT ROUTING INFORMATION: BANK: Fifth Third Bank, Indianapolis, Indiana ACCOUNT: 7654627947 ROUTING: 074908594 AVA #: 042 000 314 "twit"- CERTIFICATE OF LIABILITY INSURANCE OP ID: 79 DATE (MmTDDIYYYY) 10/02/12 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(ios) must bo endorsed. If SUBROGATION IS WAIVED, subject to the terns and conditions of tho policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsomont(s). PRODUCER Hylant Group Inc- Indianapolis 301 Pennsylvania Parkway, #201 Indianapolis, IN 46280 W. Michael Wells 800- 678 -0361 317 - 817 -5151 INSURED City of Carmel Steve Engelking One Civic Square Carmel, IN 46032 CONTACT Marianne Uban NAME: PHONE 317 - 817.5136 PHONE Eat. ADDRESS: RL marianne.uban @hylant.com PRODUCER CARME80 CUSTOMER lot I (AAC No): 317 -817 -5151 INSURER(S) AFFORDING COVERAGE INSURER A:Travelers Insurance Companies INSURER B: INSURER C INSURER 0 : NAIC # INSURER E : INSURER F • REVISION NUMBER: THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PC ICY 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 LTR TYPE OF INSURANCE ADDESUBR INSR WVD POLICY NUMBER POLICY EFF IMMIDO/VYYYI POLICY EXP (MMIDDNYYY) LIMITS GENERAL LIABILITY COMMERCWL GENERAL LIABILITY OCCUR EACH OCCURRENCE DAMAGETCRE a PREMISES (Ea occurrence)_ $ 5 5 CLAIMS-MADE MED EXP /Any one person) PERSONAL B PDV INJURY $ GENERAL AGGREGATE 5 GE IL AGCREGtTIE LIMIT APPLIES PER: � LOC POLICY i1 ¢� PRODUCTS - COMPIOP AGO S 5 A A AUTOMOBILE — X — X LIABILITY ANY AUTO ALL OWNED AU IDS SCHEDULED AUTOS HIRED AUTOS NON-CRANED AUTOS Comp. /Coll 8103036P64A 8103036P64A 01/01/12 01/01/12 01)01/13 01/01113 COMBINED SINGLE LIMIT (Ep accident) S 2,800,008 BODILY INJURY (Per person) S BODILY INJURY (Per acad#nt) 5 PROPERTY DAMAGE (Per acodenl) $ Comp Ded S 2,500 Coll Ded s 2,500 UMBRELLA LIAB EXCESS LIAO I I OCCVR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE 5 HDEDUCIIBLE RETENTION $ 5 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY y I N ANY PROPRIETOR /PARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED'? (Mandatory In NH) 11 yes descnbe utter DESCRIPTION OF OPERATIONS below NIA 1 VC STATU- OTH• I I Eft _ITORYLWIIS E.L. EACH ACCIDENT 5 E. L. DISEASE - EA EMPLOYEE $ F.L. DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addlaonal Roma rkS Schedule II more space I required) Re: 2 - Horton 623 -1 WT Ambulance and Equipment VIN 1FDUF4GT9CEC39654 AND VIN 1FDUF4GT0CEC39655 ..ref r r. r.... m– EVIDENC Evidence of Coverage I 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 ACORD 25 (2009/09) -2009 ACORD CORPORATION. All rights resery ed. The ACORD name and logo are registered marks of ACORD NOTEPAD INSURED'S NAME City of Carmel CARMEBD PAGE 2 OP ID: 79 DATE 10102/12 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 TRAVELERS INSURANCE COMPANIES POLICY #2103036P64A POLICY PERIOD: 1/1/12 -13 AUTO PHYSICAL DAMAGE: COMPREHENSIVE DEDUCTIBLE: $1,000 COLLISION DEDUCTIBLE: $1,000