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2013 Police schedule 15 pay request 20 Lease 2013 — Sch # 15 (Police Dept.) Payment Request # 2013-20 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: Paper-Lite Amount: $4,536.00 Description of Equipment Item Cost: Laserfiche Product Rio Licenses Dated: October 17, 2013 LESSEE: City of Carmel One Civic Square Carmel,IN 4,032 By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Paper-Lite 1711 Wood Valley Drive Carmel, IN 46032 PAGE 1 ' 7 ® DATE(MM/DDIYYYY) ACC: R° CERTIFICATE OF LIABILITY INSURANCE 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 NAAME: Marianne Uban Hylant Group inc Indianapolis ow,No.Eet):317-817-5136 FAX No):317-817-5151 301 Pennsylvania Parkway,#201 E-MAIL s:marianne.ubanash lant.com Indianapolis IN 46280 Y INSURER(S)AFFORDING COVERAGE NAIC II INSURER A:Charter Oak Fire Insurance Co 5615 INSURED CARME80 INSURER B: City of Carmel INSURER C: One Civic Square Carmel, IN 46032 INSURERD 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/. LTR I TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY)I I11/1M DDIYYYY) LIMITS A GENERAL LIABILITY ZLP14T62033 1/1/2013 1/1/2014 EACH OCCURRENCE $2,000,000 X DAMAGE TO RENTED $50,000 COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) 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 PRO- LOC $ JECT 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 PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N 1 A - (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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 I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD r7D T .�� Invoice 1711 Wood. Valley Drive Carmel, IN 46032 DATE INVOICE# 10/11/2013 4854 BILL TO City of Carmel Three Civic Square Carmel, IN 46032 Attn:T. Crockett P.O. NO. TERMS DUE DATE 25439 Net 30 11/10/2013 DESCRIPTION QTY RATE AMOUNT Laserfiche Product Rio Licenses w/LF Forms 6 660.00 3,960.00 LSAP-Lasertiche Software Assurance Plan pro-rated until 4/30/14 6 96.00 576.00 Subtotal $4,536.00 Sales Tax (0.00) $0.00 Total $4,536.00 Phone# Fax# E-mail 812-350-5044 317-581-9409 nancyagopaperlite.com