Fireworks Display Hold Harmless Agreement Form
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1FIREWORKS DISPLAY HOLD HARMLESS AGREEMENT
Town of Clayton
Ref: NY State Penal Law, Article 405.00
Between the Town of Clayton and _________________________________,
(Print name of Fireworks Contractor)
Witnessed:
1. _______________________ (Contractor) agrees to release, indemnify, and hold harmless the Town of
Clayton, its officers and employees, from and against any loss, damage of liability, including attorney’s
fees and expenses, incurred by the latter and their respective employees, agents, or other
representatives arising out of or in any manner relating to the manufacture, installation, firing and
disassembly of any pyrotechnic equipment or device and / or the supervision and presentation thereof:
2. The applicant (Contractor) has furnished the Certificate of Insurance with limits of liability described
below:
a. Workers Compensation / Employers Liability____________________
b. Automobile Liability: _______________________________________
c. General Liability: __________________________________________
d. Umbrella Liability: _________________________________________
A true copy of the Certificate of Insurance is attached indicating the Municipality and applicable
associations, recreations, or committees formed by the Municipality to organize the “event” named as
additional insured on all liability policies.
Event Name: ________________________Date: _________Time:________
Rain Date if Applicable: _____________________Time: _______________
Name of Applicant (Fireworks Contractor / Operator) (print): __________________________________
Signature of Applicant (Fireworks Contractor / Operator): _______________________Dated: ________
Signature of Witness: ___________________________________________________Dated: __________
Name of Applicant (Event Sponsor/Organization) (print): _____________________________________
Signature of Applicant (Event Sponsor/Organization): ___________________________Dated: ________
Signature of Witness: ___________________________________________________Dated: __________
Required Documents Attached:
Event Sponsor/Organization: Proof of Insurance ($1 MIL Liability Minimum) & Copy of Contract Between Sponsor
and Contractor
Fireworks Contractor/Operator: Proof of Insurance ($1 MIL Liability Minimum), Proof of Alcohol, Tobacco &
Firearms (ATF) License & Site Plan for display.
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