Block Party Planning Guide - City Of Selkirk (Page 13 of 14) in pdf

city of selkirk • block party planning guide

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Block Party Event Organizer / Group Waiver and Release of Liability

Schedule ‘C’

Event Organizer/Group Name:

Block Party Location:

Event Date:

It is mandatory to have liability insurance for any event occurring on the public right of way. To obtain a quote from your

insurance agent, provide the details of the Block Party closure and include the following paragraph to explain the type and

amount of insurance required:

THE APPLICANT shall maintain, pay and provide the City with a certified true copy of a Certificate of

Insurance of a Comprehensive General Liability insurance policy in a form satisfactory to the City

Solicitor in the amount of no less than Two Million ($2,000,000.00) Dollars all-inclusive, with The City

of Selkirk being named as an additional named insured and a cross-liability clause thereon, in connection

with the work permitted to be undertaken hereunder prior to the commencement of the said work.

Deductibles to be acceptable to the City and are to be borne by THE APPLICANT. THE APPLICANT shall

maintain the policy of insurance until the total Performance of the said event.

A true copy of the certificate of insurance must be forwarded to: The City of Selkirk – 630 Sophia Street Selkirk, MB R1A

2K1. Your agent may email or fax a copy to: .

ON BEHALF OF THE ABOVE EVENT/GROUP, I expressly WAIVE, RELEASE and DISCHARGE the City of Selkirk, it’s officers,

agents and employees or any other person from any and all LIABILITY for any death, disability, personal injury, property

damage, property theft or actions, including any alleged or actual negligent act or omission, regardless of whether such

act or omission is active or passive which may occur to myself or members of my organization/group or our heirs in

connection with our participation in the above-described event.

I fully understand and acknowledge that the CITY OF SELKIRK is relying on my representation that I have authorization to sign

this document and that I will provide all members of my group a completed copy of this Waiver prior to our participation.

I expressly INDEMNIFY AND HOLD HARMLESS the City of Selkirk, it’s elected and appointed officers, agents and employees

from any and all liabilities or claims made by me or my organization/group, my/our heirs and any other individuals or

entities as a result of any of my/our actions in connection with my/our participation in this event except those claims

arising from the sole negligence or sole willful conduct of the City of Selkirk, its officers, employees, volunteers or other

representatives. Such indemnification includes liability settlements, damage awards, costs and attorney fees associated

with any such claims.

I hereby certify that I have read this document, understand its content and am authorized to sign this document on behalf

of all members of this event/group I represent.

Signature:

Name (print):

Title:

Address:

Date:

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Block Party Planning Guide - City Of Selkirk Page 13