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Town of Wappinger Little League Supervisor Office FOR INTERNAL USE ONLY Received by: Christine Fulton J sica Fulton Date Received: ~ /~ / L Serial #: -S..L pplication ^ $100.00 ~ Cert. of LI Notified Recreation (dater Name of Organization or Group Agreement for the Use of the Town Hall Facilities for Meetings OCT p 12012 2010-01-19 JCM ceivedTown of Wappinger Agreement for the Use of the Town Hall Facilities for Meetings Name of person G. the Address or Group ~Y7l,~v ~, Phone No. This will confirm the arrangements being requested for your groups' use of the Wappinger Town Hall Facilities, as noted below: (r.~ Senior Citizens Room () Large Meeting Room () Other: Specify: The group is not expected to exceed persons Date(s): >i ,~y rz Time: '~„p,~ z~® ~',Glr'"~- 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. h CERTIFICATE OF LCABILlTY i[~SU(~~~,~~UL~LUJ ~~ DATE 2~O~f1~ Keystone Risk Managers, LLC 1995 Point Township Dri~~e Northumberland, PA 17867 ADDITIONAL NAMED INSURED: i TOt+1N ©F WAPP INGER ROB WILSflN 15 M I DI?LEPUSH R D WAPPINGERS FALLS SEF' 2 8 2012 NN OF WAPPING TOWN CL AMERICAN Lt NY 12590 CERTIFICATsE ~ G3a1716-1 2 32 17 NSURERS 14~FORDING COVERAGE: INSURER A: !LEXINGTON INSURANCE COMPAN INSURER B: ! NATI®NAL UNION FIRE INSURANC (Non-Liability ~ COMPANY OF PITTSBURGH, PA INSURER C: (ICHARTIS 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 CONTRAG: OR OTHER DOCUMENT WITH RESPECT TO WHICH TH15 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE=AFFORDED BY THE`"~POtIGES DESCRIBEL) ~iERE1N ]S S19BJECT TO •ALL THE TERivIS, EXCLUSiOidS AND CONDITIONS OF SUCH ..,-., ,..,.-~ enno~n Arc I Ineirc cunmtnl nnev L;IA~fFiRFFN~RFnIiCFD RY,i?AID~CLAIMS. __ '. ;..{' ;R 'R ADD'L INSRD • ~ TYPE OFINSURANCE ~ ' ' ~POLICYNUMBER POLICY EFFECTIVE " : DATE MM/DD/VYVY 'POLICY EXPJRATlON DATE MM/DD/YYYY ' LIMITS GENERAL LIABILITY ; EACH OCCURRENCE ~ ~ X X OCCURRENCE 9472464 1 /31 /2012 1 /O1 /2013 I GENERALAGGREGATE ~+ ~ X INCL. PARTICIPANTS Property Dama a Deductible: $250 , PRO AG R GOMf OPS ~ , ! I EXU LABU E ,~ ~ U X SEXUAL ABUSE I SEXUAL ABUSE ~$ ~ ~ ANY ONE MEDICAL PAYMENTS ER N ' EACH LOSS $1,000,000 A X DIRECTORS & OFFICERS 2421 rq.3b7 1 /01 /2012 1 /01 /2033 AGGREGATE $1,000,000 q X 01000$41 t 1 /01 !2012 1 /01 !2013 EACH LOSS $35,000 CRIME COVERAGE Crime Deductible: $250 Property/$1,000 Money AGGREGATE NONE As in Master Policy As in Master j X SPORTS EXCESS ACCIDENT SRG9i 05434 ~ 1 f 01 /~.O 12 i 1 / O 1 . ~~ ~ 3 Med. Max stoo,ooo 55D D d Policy Excess e . "X" INDICATES COVERAGE SELECTED FOR ADDI s wN1at_ rvHnrttu orvaursty ADDITIONAL INSURED Who is an insured (SECTION II) of the General Liability policy is amended to include as an insured the person or organization shoavn in the schedule, bul only with respect to liability arising out of the above named Little League's maintenance or use of ball fields, or other premises loaned, donated, or rented to that Little League by such person or organizations and subject to the following additional exclusions: 1. Structural alterations, new construction, maintenance. repair or demolition operations performed by or on behalf of the person or organization designated in the Schedule unless performed by the above named Little League and 2. That pars of the ball field or other premises not being used by the above named Little League NAME AND ADDRESS OF PERSON OR ORGANIZATION: TOWN OF WAPPINGER 2. WAPPINGFRS CENTRAL SCHOOL DISTRICT 3. VILLAGE OF WAPPINGERS FALLS Inlcl IRFn Little League Baseball Risk Purchasing Group, Inc. 533 U.S. RT. 15 HIGHWAY South Williamsport, PA 17702 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES TC THE ABOVE NAMED LITTLE LEAGUE BE CANCELED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING INSURER OR THEIR REPR~fIiJTATIVE WILL MAIL 3(i DAYS WRITTEN NOTICE TO THE DESIGNATED PERSON OR ORGANIZATION AT THEIR lA4'~T KNOWp ADDRE$~ TO.US. ,.' J AUTHORIZED REPRESENTATIVE `'