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• City of South Bend Special Events Committee
<br />Indemnity & Hold Harmless Agreement
<br />Date: , ;Zy"L 3
<br />Event Name:
<br />Organization
<br />Event Date: c7i, - 7-"1— ,2!UV3
<br />Applicant (Contact) Name: ,� ., s✓!.si�r/a-,✓
<br />Applicant (Contact) Phone: _ 7 S�- s 2a - o.� c Alt. Phone:
<br />Email: iti to e---v !;2 ,c a Ss �,, 1,�&a"-
<br />Address: City/State/ZIP: 5 .. �,4t 0i,
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<br />Event Location (Please describe): Al
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<br />Length orEvent (Dates
<br />Imes):
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<br />Insurance Amount: This event is insured for no less than $700,000 per occurrence and $1,000,000 in aggregate,
<br />• and the certificate of insurance includes a rider naming City of South Bend, Special Events Committee, and Board
<br />of Public Works as additionally insured for the event.
<br />Organization Name: sfra�ii�•.�' ��reos agrees to indemnify, defend
<br />and hold harmless the Civil City of South Bend, Indiana, from any, iability, loss, costs, damages or expenses,
<br />including attorney fees, which the Civil City of South Bend, Indiana, may suffer or incur as a result of any claims
<br />or actions which may be made against the City, its agents, employees, or subdivisions by any person, including a
<br />participant in the activity, arising out of the approval of this request by the Civil City of South Bend, Indiana,
<br />through the Board of Public Works, to close a portion of the public right-of-way for the event described above,
<br />or for any harm or damage alleged to have occurred because of the holding of the special event. The
<br />undersigned certifies that he/she is authorized to bind the APPLICANT to these terms.
<br />Signed on this Date: "� p;;�- -5
<br />Authorized Organizer Signature
<br />• Printed Name and Title
<br />
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