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2013 police schedule 15 pay request 17 Lease 2013 — Sch # 15 (Police Dept.) Payment Request # 2013-17 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 February 14, 2013 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: CopsGear.com Amount: $20,710.00 Description of Equipment Item Cost: 10 Radars Dated: August 13, 2013 • LESSEE: City of Carmel One Civic Square Carmel,I 6032 6.r ,�. By: " x Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: CopsGear.com 3065 West US Highway 30 Columbia City, IN 46725-8193 • PAGE 1 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM3DD(YYYY) 3/25/2013 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 NAME: Marianne Uban Hylant Group Inc Indianapolis A/C No.Exu:317-817-5136 FAX No):317 817 5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADDRESS:marianne.uban @hylant.com INSURER(S)AFFORDING COVERAGE NAIC ft INSURER A:Charter Oak Fire Insurance Co 25615 INSURED CARME80 INSURER B: City of Carmel INSURER C: One Civic Square INSURER D: Carmel, IN 46032 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1271512319 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 S POLICY EFF POLICY EXP TYPE OF INSURANCE NSR WVD POLICY NUMBER IMMIDDIWYY) (MMIDDIYYYY) LIMITS A GENERAL LIABILITY ZLP14T62033 1/1/2013 1/1/2014 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY PR S l RENTED PREMISES E MISEIEaoccurrence) $50,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY jECT LOC $ A AUTOMOBILE LIABILITY H8103036P64ACOF13 1/1/2013 1/1/2014 COMBINED SINGLE LIMIT (Ea accident) $2,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) X Comp X Coll Comp/Coll Ded $2,500 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) ADDITIONAL NAMED INSUREDS: CARMEL CLAY PARKS BUILDING CORPORATION; CARMEL CLAY BOARD OF PARKS& RECREATION; CARMEL REDEVELOPMENT COMMISSION; CARMEL REDEVELOPMENT AUTHORITY; CARMEL CITY CENTER COMMUNITY DEVELOPMENT CORPORATION Re: Various Police Equipment/Vehicles CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Huntington National Bank& its assignors and ACCORDANCE WITH THE POLICY PROVISIONS. assignees c/o American Lease Insurance AUTHORIZED REPRESENTATIVE 654 Amherst Rd., Ste. 335 Sunderland MA 01375 J ' I a ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Invoice ,f P R.,. Date Invoice# a POLICE • FIRE • PUBLIC SAFETY& MORE 8/8/2013 1 120 3065 West US Highway 30 (P) 260-244-3333 Columbia City. Indiana 46725-8193 IP Fax: 310-230-5604 Bill To Ship To Carmel Police Dept Carmel Police Dept. L. Joe Bickel . Lee Goodman 3 Civic Square 3 Civic Square Carmel, In 46032 Carmel, IN 46032 P.O. No. 1 Terms Due Date Rep Service Date Via FOB- Net 30 9/7/2013 AM 8/8/2013 USPS t Item Qty Description ! Unit Price Amount CRS 057 Gold... 10 (CRS57) Kustom Signal Golden Eagle II dual 1,980.00 0 19,800.00 antenna, Ka-Band DCM w/TruTrak CRS 061 displ... 10 CRS 61 displ sep kit R: plates seperates display 57.00 0 570.00 face from the counting unit shipping 10 Fixed Shipping-Per CRS 057 Item 34.00 340.00 1 Thank you for your business. . Subtotal S20.7I0.00 s r Sales Tax (0.0%) $0.00 Total $20,710.00 Overdue Invoices will be Subject to a Fee Equal to 10%of the Total Charges. Thank you for your business.