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Little League (2) RECREATION COMMITTEE CHAIR TOWN OF WAPP1 GER SUPERVISOR Ralph J. dolt Lori Jiava RECREATION DEPARTMENT TOWN BOARD Jessica Fulton, 'Director WiIllamn H. Beale Donna Lenhart,Secretary William Ciccarelli John Fenton 20 MIDDLEBIJSH ROAD Michael Kuzmicz. APPIN ERS FALLS, NY 12590 Recreation Department WWW.TO,WNGFWAPPINGER.IJS TOWN CLERK (845) 297-41.58 - Main Joseph P. Paoloni (845) 297-0720-Direct (845)592-7433- Fax TOWN OF WAPPINGER RECREATION FACILTY Town of Wappinger 2017 Facility Usage Fees Facility # o1 Participants Fee Pavilion Use one day Less than. 50 75.00 Pavilion ' se - one day More than 50 $150.00 Park use ® cine day Less than 50 75°00 Park use - mine day More than 50 $150.00 Apphcant Info Nariie; of hidivic LU11 01- i Ir Cell: e; E''1T3a11: p y JAN 0 2 201'8 iw-ehl, r cvv TOWN OF WAPPINGER ... , .. Failure to comply with these regulations will result-Ln immediate revocation offuture faci ty uses. I have read and understand the regulations for the use of facilities in the Town of Wappinger and will comply with these regulations. The undersigned warrants and represents that he/she/they have the authority to sign this agreement on behalf of (Name of org;irnzation) (Name of Organization) ac-61(1 shall indemnify and hold harmless the Town of Wappinger against all claims on account of injury, loss or damage arising or alleged to arise out of or in connection with the occupancy of the Town of Wappinger premises including all expenses incurred by the Town of Wappinger in the defense, settlement or satisfaction thereof including expenses of legal counsel. In addition, (Name oforgarlization) &,. ,6.. has provided the Town of Wappinger with a Certificate of Insurance, which indicates a current Commercial General Liability policy is in force, with (Xunc of'oiga.rnizat on) as the first name insured. The occurrence limit t - must indicate a limit riot less than $1,000,000.00. The insurance company must have an A.M. Best's rating of "A" or better. Town of Wappinger is to be listed as additional insured on a primary, non-contributory basis. No approval is granted or implied unless and until all requirements as outlined above has been submitted to, approved and accepted by the Town of Wappinger Recreation Director. I UNDERSTAND THAT THISAPPROVAL DOESNOTBECOME EFIECTIVE UNTIL THEFEE HAS BELVPAIDAAD THE$1,000,000.00 LIA BHJT -EVSURANCEPOLICYNAAMVC TOWN OF WAPPINCER LISTED ASAD.DITIONAL INSURED ONA PRIMARY, NON CONTAW70RYBAHS IS SUB . //Ar Signat re Print bdte Fee Paid: Insurance: Date: Rec Director Signature: 2!20117CERTIFICATE OF LIABILITY INSURANCE on12/2� 17 1 PpoaucErt CERTIFICATE#: 2321716-2018-1 2 3217 Keystone Risk Managers, LLC 1995 Point Township Drive Northumberland, PA 17867 INSURERS AFFORDING COVERAGE: ADDIT€ONAL NAMED INSURED: INSURER A: Lexington Insurance Company TOWN OF WAPPINGER AMERICAN LL INSURER B: National Union Fire Insurance Company of Peter McGowan 14 Hamilton Rd (Non-Liability) Pittsburgh, PA Wappingers Falls,NY 12590 INSURER C: AIG Specialty 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 MAY 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 BEEN REDUCED BY PAID CLAIMS, INSR ADO'L IfISRO POLICY EFFECTIVE POLICY EXPIRATION LTR NAMt;D TYPE OF INSURANCE POLICY NUMBER DA'YE IMMfoDMM) DATE(MWDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A X X OCCURRENCE 611225822 01/01/2018 01/02/2019 GENERAL AGGREGATE $2,000,000 X INCL PARTICIPANTS Property Damage Deductible: $250 PRODUCTSICOMP OPS $1,000,000 AGGREGATE Sexual Abuse $1,000,000 X SEXUAL ABUSE OCCURRENCE Sexual Abuse AGGREGATE $2,000,000 MEDICAL PAYMENTS Any One Person A X DIRECTORS&OFFICERS 019130066 01/01/2018 01/02/2019 EACH LOSS $1,000,000 AGGREGATE $1,000,000 C X CYBER LIABILITY COVERAGE 018254546 01/0112018 01/02/2019 LIMIT OF LIABILITY $100,000 PER CLAIMS MADE LEAGUE AGGREGATE S&P SECURITY AND PRIVACY LIABILITY $100,000 PER LEAGUE SUBLIMIT OF LIABILITY RETROACTIVE DATE CONTINUITY DATE INSURANCE $1,000 PER LEAGUE RETENTION POLICY INCEPTION POLICY INCEPTION REGULATORY ACTION SUBLIMIT OF $100,000 PER LEAGUE SUBLIMIT OF LIABILITY LIABILITY $1,000 PER LEAGUE RETENTION EM EVENT MANAGEMENT INSURANCE $100,000 PER LEAGUE SUBLIMIT OF LIABILITY NOT APPLICABLE POLICY INCEPTION $1,000 PER LEAGUE RETENTION CRIME COVERAGE EACH LOSS $35,000 Crime Deductible:$250 Propertyl$1,000 Money AGGREGATE NONE As in Master Policy: As in Master Policy B X SPORTS EXCESS ACCIDENT SRG9105434 01/01/2018 01/0212019 Med.Max.$100,000 Excess Deductible $50 "X11 INDICATES(;OVERAGE(SISELECTED FOR ADDITIONALMED INSURED ADDITIONAL INSURED Who Is an Insured(SECTION II)of the General Liability policy is amended to include as an insured the person or organization shown in(he schedule,but only with respect to liability arising out of the above named Little League's maintenance or use of ball fields,or other premises loaned,donated,or rented to that Little League by such person or organizations and subject to the following additional exclusions: 1.Structural alterations,new construction,maintenance,repair or demolition operations performed by or on behalf of the person or organization designated in the Schedule and/or performed by the above named Little League;and 2. That part of the ball field or other premises not being used by the above named Little League. NAME AND ADDRESS OF PERSON OR ORGANIZATION: INSURED CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE D1ELIVERED IN ACCORDANCE Little League Baseball Risk Purchasing Group, Inc. WITH THE POLICY PROV S. 539 U.S. RT.15 Highway South Williamsport, PA 17702 w , AUTHORIZED EPRIsENTATIVE RECREATION COMMITTEE CHAIR TOWN OF WAPPINGER SUPERVISOR Ralph J. Holt RichardL.Thurston RECREATION DEPARTMENT TOWN BOARD Jessica Fulton, Director ,a r j -' William H. Beale Donna Lenhart,Secretary :-, - �d r Angela Bettina Robert Johnston 20 MIDDLEBUSH ROAD .m FEB 0 6 2018 Michael Kuzmicz WAPPINGERS FALLS, NY 12590 Recreation Department WWW.TOWNOFWAPPINGER.US TOWN OF WAPPINGERTOWN CLERK (845) 297-4158 - Main TOW Cl.,ERK Joseph P. Paoloni (845) 297-0720 - Direct (845)S92-7433- Fax TOWN OF WAPPINGER. RECREATION FACILITY REQUEST Town of Wappinger 2018 Facility Usage Fees Facility # of Participants Fere Paan Use - +one day Less than 50 $ 75.00 Pavilion Use - one day More than 50 $150.00 Park use - one day Less than 50 $ 75.00 Park use - one day More than 50 $150,00 Applicant hnfa Name ofIndividual or L' LSponsoring Organization. Address. ` Designated contact: t. e-- Phone. Cell: Email: �