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11 <br />City of South Bend Special Events Committee <br />Indemnity & Hold Harmless Agreement <br />Date: _26L <br />Event Name:' <br />Organization: <br />Applicant (Co <br />Applicant (Contact) Phone: 5 94 - Sl-o -U �9 S" Alt. Phone: <br />Email: fe 4159 dsrs. <br />Address: G-S % G4e: 7!% 17 City/Statemp: o..., +✓ �/�iif <br />Event Location (Please describe): 41 <br />4 WAAeS P1 Y`4 w 4 )"Tt : 7'0 1— k- <br />Length of Event(Dates/Times): Xa.eS °,Vqi 1-7 ?Y' <br />Insurance Amount: This event is insured for no less than 5700.000 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: As a sw .-,i agrees to indemnify, defend <br />and hold harmless the Civil City of South Bend, Indiana, f m any liability, 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: a y� <br />Authorized Organizer Signature <br />Printed Name and Title <br />0 <br />