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Home My WebLink AboutProcession - Real Services, Inc. - Alzheimer's & Dementia WalkI w 1 � k � i � y l �:: - �r -� FROM: SUBJECT: SPONSOR: DATE OF EVENT: DATE DUE: FAX OR E-MAIL TO: INTER -OFFICE MEMORANDUM BOARD OF PUBLIC WORKS DATE SENT: 3/29/2017 Ed Gleckler, Traffic & Lighting Federico Rodriguez, Fire Department Matt Longfellow, Engineering JKara Wood, Park Department Lt. Gene Eyster, Police Department Jill Sciccitano, Downtown South Bend Marcia Qualls, Streets Legal Department Linda M. Martin, Clerk 401- PROCESSION RECOMMENDATION Real Services Alzheimer's & Dementia Services June 17. 2017 April 4, 2017 235-917111martin southbendlin. ov RECOMMENDATIONS AND COMMENTS: By Date PERNIITIAGREEMENT FOR A PROCESSION 1. Sponsor shall reimburse the Board for the actual cost to the City for the event, if deemed necessary. 2. Sponsor shall provide to the Board a Certificate of Insurance showing a liability policy in full force and effect with limits of $300,000.00 per occurrence and $5,000,000.00 aggregate and the City of South Bend listed as an additional named insured for this event. 3. Sponsor shall provide to the Board all additional licenses, permits and documentation required for the event. 4. Sponsor agrees to abide by all terms and conditions of the Board's policy governing walks, runs, parades or other similar event adopted by the Board on March 3, 1985. 5. In order to ensure public safety during the event, the Board agrees to furnish traffic planning, materials, equipment and personnel as deemed necessary by the Police Department Traffic Bureau, the Bureau of Traffic and Lighting, and, where applicable, the Board of Park Commissioners. 6. Sponsor acknowledges that the Police Department reserves the right to change this route for safety purposes. 7. In consideration for approval by the Board and the use of the sidewalks for the purposes set out above, the undersigned agrees and undertakes to hold the Civil City of South Bend, Indiana, free and harmless from any liability loss, costs, costs, damages or expenses, including attorney fees, which the Civil City of South Bend may suffer or incur, as a result of any claims or actions which may be made by any person, including a participant in said activity, arising out of the approval of the request to use the sidewalks indicated in the City of South Bend. The undersigned certifies that he/she is authorized to bind the above mentioned sponsor to the terms hereof. S. Notification of approval/denial of this request will be issued by return of this form, upon signed authorization by the Board of Public Works I understand the above rules and regulations and that this application may be denied based on any false or incomplete information. Sponsor Signature a�L� '12 Printed Name .S Titlei� Il BOARD OF PUBLIC WORKS APPROVAL 2kw_,� L Member Member Member Date RETURN FORM TO: 2 Hoard of Public Works 1316 County -City Building 227 West Jefferson Boulevard South Bend, IN 46601 Phone: (574) 235-9251 • Fax: (574) 235-9171 9 it -Mail: publicwks@southbendin.gov A� �� CERTIFICATE OF LIABILITY INSURANCE DATE (MMlDDIYYYY) 3/24/2017 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 cedWeate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. It SUBROGATION IS WAIVED, subject to the terns 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 andorsement(s). PRODUCER Gibson Insuzanae Agency, Inc. 130 S Main St, $te 400 PO Sox 11177 South send IN 46601-0177 UAT,�CT Debbie Hull fHONE (800)814-2122 c (000)036-212x H-KAIL .dhull®gibsnnins.aom INSURE s AFFORDING COVERAGE NAICp WSURERA,,Cincinnati Ins Cc 10677 INSURED REAL Services, Inc. 1151 S Michigan St PO Sox 1835 South sand IN 46634 tNSURERs:Cincinnati Cas Co 2866S INSURERC: INSURERD: INSURER-E. 1 INSURER F I rnVFRer.Fs r r-RTIRIr:'OTr- NImaFRCCL1663016973 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. NOT%MTHSTANDING 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 LTR TYPEOPINSURANCE POUCYNUMBEIR M D EFF PO pC Il€ LIMITS 8 COMMERCIAL GENERAL LIABILITY CLJMSMAE OCCUR SCA0006252 7/1/2016 7/1/2017 EACH OCCURRENCE S 1,000,000 g V g MEDEXP(Anyoneperson) S 1,000,000A S 10,000 PERSONAL & ADV INJURY S 1,000,000 GENLAGGREGATE LIMIT APPLIES PM POLICY ❑,ECT ❑ LOC OTHER: GENERALAGGREGATE S 31000,000 PRODUCTS -COMPIOPAGG S Included PmdudsAggmgate S 3,000,000 A AUTOMOBILE LL ABILITY X ANY AUTO A�pEO AUTCr LEO NON -OWNED HIRED AUTOS AUTOS SCA0006252 7/1/2016 7/1/2017 O SINGMIT Es sodden S 1,000,000 BODILY INJURY (Per parson) S BODILY INJURY (Par amdent) S PROP�� DAMAGE Par, S Medical payments S 5,000 A $ UMBRELLA LIAD EXCESSUAB HCLAIMS-MADE OCCUR BCA0006262 7/1/2016 7/1/2017 EACHOCCURRENCE $ 2,000,000 jIGGREGATE S 2,000,000 D 0 S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIAARTNEREXECUTIVE YIN FFIOCERIMEMBER EXCLUDED? (Mandatory[n NH) H Yes, deraihe under DESCRIPTION OF OPERATIONS below N 1 A SWCO26750101 7/1/2016 7/1/2017 X i OTH- EL. EACH ACCIDENT S 500 000 E.L. DISEASE • EA EMPLOYEE S 500,000 E.L. DISEASE - POLICY LIMIT 5 500 000 DESCRIPTION OPOPERATIONS1LOCATIONS !VEHICLES(ACORD 1011, Additional Remarks Schedule. maybe attached If more space Is required) City of South Send is additional insured regarding the General Liability for the June 7, 2017 Alzheimer's and Dementia Walk. Board of Public Works 227 West Jefferson 1316 County -City Building South Bend, IN 46601 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Ins Agency/DEHL 1988-2014 ACORD CORPORATION. All rlahts reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025wimtt Additional Named Insureds Other Named Insureds REAL Services Foundation, Inc Additional Named Insured REAL Services Housing, Inc Additional Named Insured OFAPPINF (02=07) COPYRIGHT 2007, AMS SERVICES INC co