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2013 Police lease schedule 15 pay request 21 Lease 2013 — Sch # 15 (Police Dept.) Payment Request # 2013-21 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: Safety Systems Amount: $1,382.40 Description of Equipment Item Cost: Vehicle mirror lights Dated: November 1, 2013 LESSEE: City of Carmel One Civic Square Carmel,IN 46032 By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Safety Systems 4113 Turner Road Richmond, IN 47374 PAGE 1 AR° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 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). CONTACT PRODUCER NAME: Marianne Uban Hylant Group Inc Indianapolis Paco.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# INSURER A:Charter OOO_ak Fire Insurance Co 5615 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. ILTR I TYPE OF INSURANCE IAINSR SWVD I POLICY NUMBER I(MM/DY/YYYY) (MM% IY DYYY)I LIMITS 1 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 8.ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 I POLICY PRO- 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 Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/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/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 1 ',/ C.�C ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Safety Systems r It 4 lit .4" E 4113 Turner Road Richmond, IN 47374 Invoice Number: 13102212 Invoice Date: Oct 22, 2013 Page: 1 Voice: 765-935-3566 Du plicate Fax: 765-935-9713 ,'a" s $ -4yr 9»a<,t• a s s« w'` a > ce o " � ill rs_ ,�,H,�"',.,.�,< �.3,� •� ". _. .s�,e�'Si'',�3..we ,9. m€ � ,��..�,e,.e..rmax .Sn..c�:rfl� - �.w'��ar��s.��..�..� �s�ir.�r. t. ,�.`�"'�+§�..m i„+wF Carmel Police Department 3 Civic Square ATTN: Teresa Anderson Carmel, IN 46032 Customer .._; ..x w•._a. gym« .��.,e�� '•.,za�e:r''�..�a.r..<.� ., ..-,:�� :.^-^:.YL�u.a�.r Cus..t„o-im. e_ ' 4� Carmel P.D. 25435 Net 30 Days Hand Deliver 11/21/13 s' i -'rDescri tion t °� Unit;PriceY Amountz tr °r 4.00 M B PI 06 JJ 345.60 1,382.40 Subtotal 1,382.40 Sales Tax Total Invoice Amount 1,382.40 Check/Credit Memo No: Payment/Credit Applied X382 40_