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HomeMy WebLinkAboutProcession - Stanley Clark School�. ,. -'� ,:,,,L:� .,:..._1 _ ._... _. - 1.� �'..-t �.;� #r_ . INTER -OFFICE MEMORANDUM BOARD OF PUBLIC WORKS DATE SENT: 7/5/2017 TO: d (eckler, Traffic & Lighting eder'co Rodriguez, Fire Department Longfellow, Engineering ara Wood, Park Department Lt. Gene Eyster, Police Department J' ciccitano, Downtown South Bend arcia Qualls, Streets Legal Department FROM: Linda M. Martin, Clerk SUBJECT: PROCESSION RECOMMENDATION -Clark Run 5K SPONSOR: Stanley Clark School DATE OF EVENT: October 14th 2017 DATE DUE: JuIV 18 2017 FAX OR E-MAIL TO: 235-9171 1 lmartin@_southbendin.gov RECOMMENDATIONS AND COMMENTS: By Date -om: Thomas Story Fax: (866) 610-8379 To: Fax: (574) 235-9171 Page 3 of 3 0612312017 3:07 PM PERMIT/AGREEMENT 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 terns and conditions of the Board's policy governing walks, runs, parades or other similar event adopted by the Hoard on March 3, 1985. 5. In order to ensure public safety during the event, the Board agrees to furnish traffic planning, materials, er:luipnient 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 pill -poses, 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, fee and harmless from any liability loss, costs, costs, damages or expenses, including attorney fees, which the Civil City of South fiend 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 helshe is authorized to mind the above mentioned sponsor to the terms hereof. S. Notification of approvalklenial of this request ivill he issued fly return of this form, upon signed authorization by the Board of'Puhlic Works I understand the above rules and regulations and that this application may be denied based on any false or incomplete information. Sponsor Signature p�_ Printed Name Title OAR D OF' P BLIG W( /"mn J, bu President Member Melter --- Member APPROVAL Member - - `r S17 Date RETURN rot7,vt To: Bwrd of Public Works 1316 County -City Buildirig 227 WC.0 Jeff rscni Soule-vaird South fiend, 1N 46601 Plione: (574) 235-9251 n Rik! (574) 235 9171 a -Mani: public-,Yksfc,�sotltftbendin.gov 2 b ACC?RV CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YM) s/13/2017 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 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). PRODUCER Gibson Insurance .Agency, Inc. GONTACT Stephen Swihart NAME: PHONE (800) 814-2122 FAf No: (800)636-2122 130 S Main St, Ste 400 E-MAI ADDRESS: gL sswihart@ ibsonins.com INSURER S AFFORDING COVERAGE NAIC # PO Box 11177 INSURERA:Cincinnati Insurance Co South Bend IN 46601-0177 INSURED INSURER e;ACcident Fund Ins Co .Amer 10166 INSURERC: _ The Stanley Clark School, Inc. INSURERD; 3123 Miami Street INSURER E : INSURERF: South Bend IN 46614-2098 rnvPPAnPR rFRTIFIrATF NIIMRFR-17 /l8 Liab 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE ❑X OCCUR PREMISE,(Ea oceTu ence $ 500,000 M£DEXP(Any one person) $ 10,000 SIP0008277 7/1/2017 7/1/2018 PERSONAL& ADV INJURY $ 1,000,000 GEN`L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMPlOP AGG $ 31000,000 JECT POLICY PRO- ❑ LOC Employee Benefits $ 3., 000 , 0 00 11 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accidani $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NO OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ _ $ j UMBRELLA LIAR EACH OCCURRENCE $ 10, 000, 000 HOCCUR AGGREGATE $ 10, 000, 000 A EXCESS LIAR CLAIMS -MADE DED I I RETENTION $ SIP0008277 7/1/2017 7/1/2018 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNEWEXECUTIVE IPER OTH- STATUTE ER E.L. EACH ACCIDENT $ 500, 000 E.L. DISEASE -EA EMPLOYFd $ 500,000 B OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N ! A WCVG113731 7/1/2017 7/l/2018 E.L. DISEASE - POLICY LIMIT $ 500,000 IF yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS! VEHICLES (ACORD lot, Additional Remarks Schedule, may be attached If more space is required) The City of South Bend is additional insured with regard to General Liability as required by written contract or agreement for the Clark Run on October 14, 2017. r P0TIGIr'_ATF I-Inl nF=P CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of South Bend THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 227 W Jefferson Stt ACCORDANCE WITH THE POLICY PROVISIONS. South Bend, IN 46601 AUTHORIZED REPRESENTATIVE G Ins Agency/STSWIH ©1988-2014 ACORD CORPORATION. All rigiats reserves. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 /9ntarHl