06
2010-01-19 JCM
Serial #:
ChrisMa~erson 0
Christine Fulton ~
Sue Rose {:)
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Town of Wappinger
Agreement for the Use of the Town
Hall Facilities for Meetings
FOR INTERNAL USE ONLY
Received by:
o Application 0 $100.00
o Notified Recreation (date:
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Agreement for the Use of the Town Hall Facilities for Meetings C h~t.s C <,/svy
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o Cert. of LI
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Date Received:
;l tJ{) /5'/'( -i(,;- 71(p/ ~yr f'1 0 'Nf-17/-
Phone o. '-,713
This will confirm the arrangements being requested for your groups' use of the Wappinger Town Hall Facilities, as
noted below:
( ) Senior Citizens Room
~ Large Meeting Room
( ) Other: Specify:
The group is not expected to exceed ;) 5 persons
Date(s): Ih '(f J 0 J .) 010 Time: /:00 I'm - 1.,; 0 of tr>
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.
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2010-01-19 JCM
Tenns 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 tennination 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:
( 4j ~~~
{{;net" ({/~v ~ cI (hss ;6/c,ruJ ~VI/fCf7.s
(Name of Group or Organization)
For:
Date: OJrJ1olo/0
Approved: l' ~f:ld?J1.-"-~
Date: ~II ()
Apr 12010 14:17 P.Ol
+
American
Red Cross
Blood Services
New York-Penn Region
825 John Street
West Henrietta, NY 14586-9780
(585) 760-5555
FAX COVER
DATE: 0 'f- 0 f-f 0
TO: ~ Yn~
Pages sent, including this cover: -.5'
FROM: BONNIE MOSAKOWSKI
PHONE:
FAX: &- Cf,s"' - ~ <77-- Y:~f?
PHONE: 585-760-5798
FAX: 585-760-5767
SUBJECT:
CERTIFICATE OF INSURANCE
DURG:ml'
}tFOR Rl:vmw
o PL:EAS:E REPLY
MESSAGE:
Here is a coPy oithe Certificate ofInsurance/ agreement that was requested for your uocoming blood
drive. If any changes are necessary, please feel free to contact me at 585~ 760-5798 or
mosakowskib@usa.redcloss.org. Thank you.
This message is intended only for the use of the individual to whom or entity to which, it is addressed and may contai
information that is privileged, confidential and exempt from discbsure under applicable law. If the reader of this
message is not the intended recipient or the employee Or agent responsible for delivering the message to the intended
recipient, you are hereby notified that dissemination, distribution, Or copying of thiscomnnmication is prohibited. If
you bave received this communication in error, please notify us immediately by telephone. Thank you.
0200
Apr 1 2010 14:17
P.02
etJ CERTIFICA TE OF LIABILITY INSURANCE DAn;; 1""M/tl1lfYYYY)
11/06/2009
PRODUCER TH[5 CERTIFICATION IS ISSUED AS A IlllATTER OF INFOfWATlON
Matsh USA Inc. (Phill\delpl1ia) ONLY AND CONFERS NO RJGHTS UPON THE CERTIFICATE
Two Logan Squats HOLDER. THIS CERTIFICATE DOES NOT AMENO, EXTEND OR I
Philadelphia, PA 19103 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. I
215.248.1000 1ax2115.24S.t399
Attn: Redcross.certrequest(rbmatsh.CQlTl
849428-SIR-CAS-09-10 NY NY CLIE MOl MAIL INSURERS AFFOR.OING COVERAGE NAte ,
INSURED INSURERA: Old Republic Insutance CQ 24147
NY PENN REGION
AMERICAN NATIONAL RED CROSS INSURER B:
82S JOHN STREET INSURER C
VIlEST HENRIETTA, NY 14585
INSUREI'l 0
INSUReR Ei: I
COVERAGES 1
TI-E POLlOleS OF IN5UltllNCE LISTED BELOW HAVEi BiEN ISSUED TO 'rrte INSURED NAMeo A.llOVE FOR THe POI.ICY PERIOD INDICATE!;).
NOTWl'THSTA/llOING ~y REQUIREMENT. TE!~M OR CONDITION OF ANY CONTRACT OR OTHEi:! DOCUMENT WITH "E!$PElCT TO WHICH THl$ ceRTIFICATE
MAya! ISSUED OR MAY PERTAIN, THe INSURANCE AFFORDED IlY THE POLICIES DESCRIBED HEREIN IS $lJaJl!cl" TO ALL THE TeRMS. EXCLUSIONS AND
CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEeN REDucec BY PAID CLAIMS,
~:'=~ TYPE OF INSURANCE POUCY NUMBeR POUCY EFFECTlIII; pouev I!xPIRAnoN LIMITS
O,lTe IMIlIIClb/YTf'/) DATE (MI'Mlllli'rYn'J
A I "eNEIlAL UASIU I T MWZZ 50533 0710112009 0710112010 t:At;H <.><,;f,;VRRENCE !i 000.000
'X c:a..4IolERCIAL GEIeAL LlABUTY ~E~6ES Ee oa:urren~' $ 5,000,000
- XJ ClAIMS MI'DE D OCCUR MEO I!XP (Any",,,, pw$on) $ 10,000
X ~IR $10J:UlOO PERSONAL &. ADI INJURY $ 5.000,000
GENERALAGGREGAT~ $ 5,000.000
GENE~AOORB3ATE L~ APPUES PER PROWCTS. COIJPIOP """"IS ;INCLUDED
Xl POUCY n ~CT n LOO
A AUTOM081~ LIA.BIUTY MWTB20665 07101J2009 07/0112010 COMSINEO SlNGl..E LIMIT
- (Ea aaidenl) $ 5.000.000
X Am AUTO
~ AU. OW;EO AUTOS aoDIL Y INJURY $
- (Per p-..n)
. SCHEtlULED AUlOS
- HIRED AUTOS
BOOlL Y INJURY $
- (Pel accid~nt) I
NON-O'NolEo AUlOS
.. ~ Auto Physical Damage - PROPERTY DAMAGE I
~ Deductible Como/Cnll $1.000 (Per eccidllnIJ $ i
GARAGE L.lADlJTV AUTO ONLY - EA ACCDENT $
R ANY AlITO OTHi:R 1HAN EiA ACe $
AUTO ONL ~ AGo $
~$$I UIWRELLAUABIUTY EACIol OCCll'lRENCE $
tJ OCCU!l. 0 CLAIMS MACE AGGRi:GA.TIO $
R $
DEOUCTIlLE $
RETeNTION $
A =-~':.:i?=:''nON ANI) MWC:1160l800 (INSURED) 0710112009 07/0112010 X I \l\CSTATlJ.. I IOJ~
A MWFEX138 (FLt 0710112009 0710112010 F.L. EACH ACCID~NT $ 1.000.000
AN'( ~O~I~AR1NERlEXECUTI\IE Y I N M\NXS867 (AL,CA.GA,MA,MI, 0710112009 07/0112010
A OFACE~BEREiXCI.UD~D? ~ MO,OH,PA,TN.VA)'" ~.L DISEASE - EA EMP~O'\l: $ 1,000,000
~andalD~~ fm..,';lo;sIl1De unaer ~L DISi:ASE - POLICY LIMIT $ 1.000,000
PECIAl. 10 S ot"",
01llY.
DESCRlPllON OF OPERA 1IOKSILDCA 11ON&IIIl!HlCLESEXCLUSlONS A,DD&O BY EII)O~ENTlSI'IiCIAL. PROVISIONS
RE: ElLOOD DRIVES TO BE HELD THROUGHOur THE POLICY PERIOD. 07/01109 TO 07101/1 O.
CERTIFICATE HOLDER
CLE-002473627.()1
CANCELlA,TION
SllOUl-p ANY OF 1IIE ABOVE llESCRlIED POUCIE$ IOE CANCELLED BEFO~ THE
TOWN OF WAPPINGER IilIPIRATlON DATE THI;I\EOF, TIlE ISSUINa IN$URER Will. ENDEAVOR TO MAIL
ATTN: SUE ROSE ~ DAYS WRITTEN NOTICE m TIlE CEIl,'l'lF1~TE HOUlIiR NA!>t1iO to THE LEFT,
20 MIDDlEBUSH ROAD
WAPPINGER. NY 12590 IIUT FAILURE TO DO SO SHALL IMPOSI! NO OBUOATION OR LIADll.ITY Of ANY KIND
UPON 1IIE INSURER, ITS AGIOO'S OR Il,EP~E9ENTA TIVES.
"~'"6n"fn~N""'rtIIl:! -e ~ C-;7.../'P'
Roger C Fall
ACORD 2512009/01)
C 1998.2009 ACOFW CORPORAnON. All Rights RllI>8rved
The ACORD name and logo are registered marks of ACORD
Apr 12010 14:17 P.03
IMPORTANT
If the Qlrtificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVEO, subject to the terms and conditions of the policy, cartain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized
n!lpresentative or producer, and the certificate holder, nor does It affirmatively or negatively amend,
extend or atter the coverage affGrded by the policies listed thereon.
Acord 25 (2009101)
Apr 12010 14:18 P.04
ADDITIONAL INFORMATION CLE..o02473627-01 DJ. TE (1\WIDbrYY)
11/0612009
PRODlJCEl{
Marsh USA Inc. (PhIladelphia)
Two L~an Square
Phllad pilla, PA 19103
215_245. 1 000 fax215.246.1 399
Attn: Redaoss.certrequ9St@mal'$h.com
849428.SIR.cAS"09-10 NY NY CLlE MOl MAIL INSURERS AFFORDING COVERAGE HAle'
INSURED INSURER F.
NY PENN REGION INSUR~ l)
AMERICAN I'IlATIONAL RED CROSS
825 JOHN STREET INSURER H
WEST HE;NRIETTA. NY 14588 INSURER t
TEXT
ATTACHING TO AND FORMING PART OF THE AMERICAN NATIONAl RED CROSS CERTIFICATE OF INSURANCE
AS RESPECTS lNORKERS COMPENSATION:
This is to certify that all Am9nean NatiQniEll Red Cross units In the follOwing states ani currently self insured through the American National Red Cross:
Alabama, California, FIOl'i(la, GeQrgia, Massachusatts, Michigan, Missouri, Ohio, PeMsylvania, Tennessee, and Virginia. .
WorI(ers CompensatIon Policy #MWC11602800;
Policy for all other states except the monopolistic Slates of NQrth Dakota. Puerto RiCO, Wallhington, Wvoming and U.S. Virgin Islands and the self-Insured
states of Alabama. Califgmill, Florida. Georgia, Massad'tutilll!ttll, Michigan, MlssOLJl'i, OIJiQ, Pennsylvanfa, Tennessee, llnd 'VIrginIa. InCludes E;mployers
Liability fot monopolistic states of North Dal<ota, Puerto Rico, Washington, Wyoming. and U,S; Virgin Islands.
.Specific Excess Workers Compensation PoliO)' #MWFEX1S8:
American National Red Cross is self-insured for WorkefS Compensation in the state of Florida. The E)!;cess L.iability limit Is Subject to II state approv9d
Self-Insured Retention.
""Specil'ie Excell$ Workers Compensation l='Olicy ;IlMWXS867:
American National Red Cross is self-insured for Workers Compensation in the followIng statell; Alabama, Canfornia, Georgia~.MassachUSEllto, Michigan,
Missouri. Ohio, PennsyIVaniiEl, Tennessee and Virginia. The Excess liability IImiUi lire subject to stata appl'Oved Self-Insured Retentionll.
TIllIl certificate is IssU8d as a malter of information only and CQnfere no rtghts upon the certificate holder.
CERTIFICATE; fiOI.DER
TOWN OF WAPPINGER
ATTN: SUE ROSE
20 MIDDLI::BUSH ROAD
WAPPINGl:R. NY 12590
A.wm~r~~11\IE
Roger C Fill
~ ~ C--;;z.
"~IIlI!l'IWtl~rn.1I
~lIll!illlljll!ffimr~~ii!1i!j~~J!!t.~,~j~ .
Apr 12010 14:18 P.OS
..........e M elazzo
CIIlll'lt R"Prilll.liI"l1atJv~
Marsh USA Inc.
Two l.ogan Square
Fhllad~phla, PA 1810:;
:ZHi 24C!111:!O FliIX. 215:14e 1399
Joann..M~u:r.C1\!lmarsh.oom
VWiW,m~lnlh.cClm
To Whom It MayConcem:
Re: Certificate of Insurance
The enclosed certificate is being sent to you to respond to your recent request.
Please note that the Red Cross has an online Memorandum of Insurance (MOl). The
Memorandum of Insurance will provide you with a more efficient way of obtaining
information about Red Cross insurance coverage and can be accessed from the
following websites:
www.marsh.com/moi?client...2077
www.redcross,org (the Red Cross public website). Left click on the heading "Working
w~h the Red Cross" and find the MOl link at the bottom of the page at liRelated Links."
Should you have any questions, the contact person listed on.the Memorandum website
is available to assist you or you may contact a Risk Management representative from
American Red Cross national headquarters at (202) 303-7290.
~ Mol",h a MdBmr.!n CfIm.,...,...