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White Gate Condo 2010-01-19 JCM FOR INTERNAL USE ONLY Town of Wappinger Received by: Joseph P. Paoloni ❑ Agreement for the Use of the Town Grace Robinson ❑ Facilities for Meetings Date Received: Serial#: IRR 2 6 2017 } ❑ Application ❑ $ioo.00 ❑ cert. MWN OF WAPPINGER + ❑ Notified Recreation (date: ) TOWN CLERK Agreement for the Use of the Town Hall Facilities for Meetings G—i PrrE ��. Name of Organization or Group , 5.-j NM c-P-"c4 - Comm uxq fi`y Ala '- Aim N1PO4+9&E12-- Name of person representing the Organization or Group t 1 �t�- Ex�rt�vE, �, R.i�I,Q. S�'��. �o rlE�1 +�1 N�►�- �� r x.553 Address _ Phone No. v This will confirm the arrangements being requested for your groups' use of the Wappinger Town Hall Facilities, as noted below: O Senior Citizens Room Large Meeting Room ( ) Other: Specify: The group is not expected to exceed �r} persons Date(s): Time: =C)o .�lry, It should be understood that groups using the Buildings' Facilities for evening meetings must select dates when Town Meetings are normally scheduled (i.e., Justice Court, Planning Board, etc.) Special requests will be considered upon their own merit, and arrangements can be made for access to, and closing, the building at the close of your meeting. You and your Organization hereby agree to adhere to the rules set forth on the attached page by signature of an authorized member of your Organization or group. The Town of Wappinger reserves the right to suspend temporarily this agreement should the Town have need of the facility for its own purposes. Advance notice will be given as soon as possible on such occasions. The Town Clerk should be informed promptly of any schedule change or cancellation of your group activities. Arrangements for access to specific area to be used should be made with the Town Clerk at the time this form is submitted. No application shall be considered approved until it has been submitted to the Town Clerk for review and Clearance. 2010-01-19 JCM 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. I 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: -- fJ& P' P . %,E:}N N0114'l i.___. For: V4wt i clv�—J;—r CC>rJh'K>M tP�I L L M (Name of Group or Organization) Date: 4 . ( I . QC>1`+— Approved: Town Clerk Date: A� CERTIFICATE OF LIABILITY INSURANCE 4/20/201�YY` 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(les)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 CONTACT Mary Burlingham Gerelll Insurance Agency, Inc. PHONE (845)265-2220 FAX Not,(845)265-4754 Corporate Park West @ Route 9 AODRIE :Meurlingham@Gerelli-Insurance.aom P.O. BOX 362 INSURER(S) AFFORDING COVERAGE MAIC p Cold Spring NY 10516 INSURER A:Philade l hia Indemnity Ins Co 18058 INSURED INSURER B-Greenwich Insurance Company 2322 White Gate Condominium Association INsuRERC:Federal- Insurance CompanV 20281 c/o Associa New York INSURER D: 11 Raymond Ave. , Ste 32 INSURER E Poughkeepsie NY 12603 INSURERF: COVERAGES CERTIFICATE NUMBER 2017-18 Master 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 TYPE OF INSURANCE ADDL UB POLICY EFF P041CY EXP LIMITS LTR POLICY NUMBER (MMAXWYYYYI 1MMIDDNYYYI GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE Fx_1 OCCUR FHFK1633752 4/3/2017 4/3/2018 M£❑EXP(Any one Person) $ 5,000 PERSONAL a ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY F7 PRO- LOC $ AUTOMOBILE LIABILITY COMET ED SINGLE LIMIT 1,000,000 _ ANY AUTO BODILY INJURY(Per person) $ AIx ALL OWNED SCHEDULED 7PKI633752 4/3/2017 /3/2018 BODILY INJURY(Per accident) $ HIRED AUTOS X NON-OWNED PROPER DAMAGE $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 15,000,000 B EXCESS LIAR CLAIMS-MADE AGGREGATE $ 15,000,000 DD I X I RETENTION$ 10,00C PPP7444:§19 4/3/2017 4/3/2018 $ WORKERS-COMPENSATION WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y 1 N I ER ANY PROPRIETORIPARTNERIEXECUTIVE❑ N 1 A E.L.EACH ACCIDENT $ OFFICERIMEMBER FXGLUDED? (Mandatory in NH) E,L DISEASE-EA EMPLOYE $ It yes describe under DESi'RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMU $ C Directors 6 Officers 227-3322 4/3/2017 4/3/2018 Limit 1,000,000 Deductible. 2,500 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required) Certificate holder is listed as additional insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Wappingers Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. 20 Middle Bush Road Wappingers Falls, NY 12590 AUTHORIZED REPRESENTATIVE Gregg Gerelli/MVS V. ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INW176(?riinnrN ni Th.Af`t%Drk -1 I- at'rio T "1 za O C. p -4 LO m v .rtD m �. A rt Q (D o o z m,a �. o CL _ -� a �' 0 O 3 f. � '� c D - 7 CL D .; ' � �ru o° g Lq ■� 4 rrD w ^u n ru. r>. 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