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• <br />Date: <br />Event Name: nn <br />• <br />Organization: �,%,3 i-T <br />Applicant (Contact) Name:. <br />e <br />Applicant (Contact) Phone: <br />City of South Bend Special Events Committee <br />Indemnity & Hold Harmless Agreement <br />�'�N1/Ilyl%119t�/_e►7:�Ts'Y/SL' l ��a�A' <br />Event Location (Please describe): <br />Length of Event (Dates/Times): <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: SaAh �iPiL��1PI, VlAkStYWOIaereestoindemnify, defend <br />and hold harmless the Civil City of South Bend, Indiana, fre(n any l5bility, 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-wayfor 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: ` D J5• 3 L4 <br />Authorized Organizer Signature <br />is <br />Printed Name and Title <br />