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2012 Fire Schedule 12 pay request 5 Lease 2012 — Sch # 12 (Fire Dept.) Payment Request # 5 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 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 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: AMK Services, LLC. Amount: $1,734.00 Description of Equipment Item Cost: Radio Batteries Dated: 1/8/14 LESSEE: City of Carmel One Civic Sq are fo Carmel, 11N '032° of. 1 ,, .� . By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original cf Payee's statement) PLEASE PAY VIA WIRE TRANSFER: PAGE 1 INVOICE AMK Services,,,7 Invoice# 3706 1555.5 Stony Cieek1/1/4y Nobi.,:sullie, IN 46060 (317)774-1867 (317 774.1869(1) SOLD Carmel Fire Dept, TO Attn: Adam Harrington 2 Civic Square Carmel, IN 46032 PAcPINNIMMINIVAIMMBENNIUM0010011.:MiatiPATEAPARIMPATERMAZSVISAIielttYPIPAP:AtEaiglikAgl: CARMFD I 24362 AMK I 12/18/2013 Net 30 12/19/2013 CREKNOWSUMIlingiMQVANIMME$103111TIONOWientMisavinmesemilaWRIMUIORRI,OFMR13.14,ENTENDEEl 20241 17 Honeywell Battery, P5100/7100/7200, 102.00 ; 1,734 00 Sales Tax 0.00 TOTAL AMOUNT '1,734.00 Pleasc; Remit I o. AMI\ Sec LL.(. 9:2,41 (.'mu ' WIllkon Road Jolinslown.Of I 43011 'fhR in ma', h Icc chaiydrs ' 1/2", {,:€ month(18°,,, the unpd,d 1,:damx,th,•ri Lh sINAc 3Alddy,pa..1 A R DATE(MMlDDlYYYY) • n CERTIFICATE OF LIABILITY INSURANCE 11DATE(M 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). ACT PRODUCER NAME: Marianne Uban Hylant Group PHONE FAX E-MAIL.Ext(:317 817 5136 {AlC,N o):317-817-5151 301 Pennsylvania Parkway,#201 Indianapolis IN 46280 ADDRESS:marianne.uban @hylant.com INSURERS)AFFORDING COVERAGE NAIC k • INSURER A:Charter Oak Fire Insurance Co 25615 INSURED CARME80 INSURER B • City of Carmel INSURER C: Migrated Location INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE tft.LMBER: 4745855 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER I(MM/DDIYYYY) (MMIDD/YYYY) A GENERAL LIABILITY IZLP14T62033 1/1/2014 1/1/2015 EACH OCCURRENCE $2,000000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $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/OPAGG $2,000,000 POLICY PRO- JECT LOC $ A AUTOMOBILE LIABILITY H8103036P64ACOF14 1/1/2014 1/1/2015 COMBINED SINGLE LIMIT _(Ea accident) $2,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accidert) X Comp X Coll Comp/Coll Ded $2,500 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS DAB CLAIMS-MADE AGGREGATE $ DEC) RETENTIONS $ WORKERS COMPENSATION VE STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE N 1 A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (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: 17-Honeywell Batery, P5100/710017200, Li-Poly • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN AMK Services, LLC ACCORDANCE WITH THE POLICY PROVISIONS, 15555 Stony Creek Way Noblesville IN 46060 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD