Little League (2) Wa V.e,,
FOR rfEl AL UST; ON ` . L
2010-01-1 9.lCl~s
Received by: P. 1'aoloali
Joseph Town Of app"' er
�
Grace Robinson cI ent for the
Date Deceived: �J t� W_._ ���&WFeacilities se Of the Tow,,
for M
Serial ; ectilgs
w 0 V 7. 7 2016 ---
Application I C�,O TOWN OF WAPPING 1
Cert. of Ly
Notified Reca•eaton. (date: N CLERK
Agreement for the Use Of the Town
Hall Facilities for
Meetings
e f Organization or G tx
Nal 7e of person representing the dr anization or
Group
Address
This will conlZr�n the arxana ��This
below: geinents being phone No.
� requested for your groups' use of the appia�ger Town.Hall Facilities,
as
Senior Citizens I�acazi•a
{ Large Meeting Roorn
{ } Other. Specify:
The grVP is not expected to
Date{s) exceed -persons
It should be understood that groups
Time; - • /
Town Meeting's are noa•nially scheduled i.e l Facilities for evenings
considered upon thein.Ow { , . ustice Court l'lar�arir��> g rlleetings z,just select dates when
Own aa�erit. and arrana Merits can be made 1,61.access to and peclosing,
of your rneetin$x. g Board, etc.) Special z'equests gill be
fire building at the close
YOU and 31our Organization hereb � agree
aut17or1zed n1cn]ber of Y our Or � pton to adhere to fire rules set ft�r t17 on the attached a
Your ganization or group.
page by signatuz"e of an
The "T'ow,a of"+�+'appillg
facilit , f er reserves
the right to suspend teaa poraril ,
,� for its or�rza laurposes. Advance 110tFce l�+f%ll be give"
) this a�.
eemeat adv en as sooza as possible on such oc clasio is za have need of file
The Town Clerk should be� iarforra�aed pz-ona�I�atly oI'ar2 � schedule Arrangements for access to specific area to be ) hedule ch•ara«
e Or la
submitted, ��sed should be inadc with the Tolwntlor"i of your rr
group activities,
Clerk at tl�e tira7e this form is
NO application shall be coaasider•ed approved zzartil it has b >-
C�'leai•anee. eera submitted to the Town cle-jr
rl,, for z'et,ie\V aaid
2010-01-19 3CM
Terms of the agreement must be strictly adhered to by the contracting group as any disregard or abuse of the rules
for use of the facilities will result in termination of use by the offending group, and they will not be granted
reinstatement.
T have read and understand the rules and regulations for the use of the Facilities in the Town of Wappinger Town
Hall, and will comply with these requirements.
Signed.:
LO
For: 'l�,c'?N 0 L R
_�T (Name of oup or Organization)
Date:
Approved:
Town Clerk
Date:
, ,CEOF LIABILITY INSURANCE .DATE I 1 23 1,
Keystone Risk Managers,LLQ
CERTIFICATE# 2 30f `16
1995 Point Township Drive
Northumberland,PA 17$67 W .
INSURERS AFFORDING COVERAGE:
ADDITIONAL NAMED lNSVREd:
� � �, ,�11 N���- � , .c s 1T, TIN4RA: XINGTON INSURANCI^COMPAA
i�E1 1 i1.T311 R WSOMPANY OFNATIONAL IPITTSBURGH,PAON FIRE NG
(Non- aty)
AIG SPECIALTY
INSURER C: INSURANCE COMPANY
COVERAGES _
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 MA)
PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS.
!R
ADD' E,OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION `LIMITS
R ;NsRa TYPE DATE MWDI3fVyYY DATE MMIDD/YYYY
EACH OCCURRENCE 0001 000
GENERAL LIABILITY ! { ;. CENERALAGGREGATrz 4i, OCA. - i
X OCCURRENCE
I PbDU0T5z0MP CPSA
X INCL. PARTICIPANTS Property Damage Deductible:$250 AGGREGATE
SEX ALAsuSE
OCCURRENCE
X SEXUALABUSE sexuALAUUSE _2, 000, ADC)f
ANY ONE
MEDICAL PAYMENTS PERSON
EACH LOSS $1,000,000
DIRECTORS&OFFICERS s�* 31:g9E rS.. 1 i0 yr2 16, /42 0 17
AGGREGATE $1,000,400
EACH LOSS $35,000
JA:S:PCO)�RTS
CRIME COVERAGE
Crime Deductible:$250 Property/$1,000 Money AGGREGATE NONE
As In Master Policy As in Master
EXCESS ACCIDENTMed.Max.$100,000 Policy Excess
Eaj G-19 5 4 3 4 /01/2016 1/0 1 0 i > Ded.$50
INDICATES COVERAGE SELECTED FOR ADDITIONAL.NAMED INSURED
ADDITIONAL.INSURED
Who is an insured (SECTION-11) of the General Liability policy is amended to include as an insured the person or organization shown in the schedule, but only with respect t
liability arising out of the above named Little League's maintenance or use of bail fields, or other premises loaned,donated, or rented to that Little League by such person c
organizations and subject to the following additional exclusions:
demolition operations performed by or on behalf of the person or organization designated in the Schedule unles
1. Structural alterations.,now construction,maintenance,repair or
performed by the above named Little League and
2. That pari of the ball field or other premises not being u he above named Little League
NAMEd by IAND ADDRESS OF PERSON OR ORGANIZATION,
TOWN C3 ' �3�tR1��.i��;1Ei-� ry?.
ISpFppj1qGERS CE1`11-RAL 13-M-100L DISTRICT
INSUREq CANCELLATION
SHOULD ANY OF THE ABOVE DESCHIBED POLICIES TO THE ABOVE NAMED LITTLE LEAGUE BE CANCELED BEFORE TI
Little league Baseball Risk Purchasing Group,Inc. EXPIFiRTION DATE THEREOF,THE ISSUING INSURER 4ii THEIR REPRESi NTATIVF WILL MAIL 39 DAYS WRITTEN NOTA
TO THE DESIGNATED PERSON OR ORGANIZATION AT THEIR KN ADDRFSS TO US.
539 U.S. RT. 15 HIGHWAY f
South Williamsport, PA 17702 AUTHORIZFD REPRESENTATIVZ ��