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HomeMy WebLinkAbout1995-142 .... 1 2 RESOLUTION NO. 95-142 RESOLUTION OF THE CITY OF SAN BERNARDINO APPROVING A LICENSE 3 AGREEMENT BY AND BETWEEN THE INTERNATIONAL SOAP BOX DERBY INC. (dba "ALL AMERICAN SOAP BOX DERBY") AND THE REDISCOVER SAN BERNARDINO 4 COMMITTEE OF THE CITY. 5 BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF SAN BERNARDINO AS FOLLOWS: 6 7 SECTION 1. The Mayor of the city of San Bernardino is hereby 8 authorized and directed to execute, on behalf of said city, a 9 License Agreement by and between the International Soap Box Derby, 10 Inc. (dba "All American Soap Box Derby") and the Rediscover San 11 Bernardino Committee of the City of San Bernardino for the 12 promotion and conduct of the All American Soap Box Derby. 13 SECTION 2. This agreement is rescinded if the parties to the 14 agreement fail to execute it within sixty (60) days of the passage 15 of this resolution. 16 I HEREBY CERTIFY that the foregoing resolution was duly 17 adopted by the Mayor and Common Council of the City of San 18 Bernardino at a regular meeting thereof, held on the 1st day 19 of May , 1995, by the following vote, to wit: 20 Counci1mernbers AYES NAYS ABSTAIN ABSENT 21 NEGRETE 22 CURLIN x x 23 HERNANDEZ 24 OBERHELMAN 25 DEVLIN 26 POPE-LUDLAM x x x x 27 MILLER x 28 45'-1'12 RESOLUTION APPROVING A LICENSE AGREEMENT BY AND BETWEEN THE INTERNATIONAL SOAP BOX DERBY INC. (dba "ALL AMERICAN SOAP BOX DERBY") AND THE REDISCOVER SAN BERNARDINO COMMITTEE OF THE CITY 1 2 3 4 5 6 7 The foregoing resolution May , 1995. Approved as to form 8 and legal content: 9 JAMES F. PENMAN City ~AttorneY 10 By: . / 11 ./ - 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1~~ . h~ ci ty ~ler~~~ 1S eQebY approved th1S _daJ of ---;-~YL~ ITom Minor, Mayor City of San Bernardino '. 95-142 1995 ALL-AMERICAN SOAP BOX DERBY UCENSE AGREEMENT (01:. .1 .,- AGREEMENT, dated th~ day 0~0Jy'1995 between and among: LICENSEE: Rediscover San Bernardino Committee, City of San Bernardino 300 North "0" Street, San Bernardino, California 92418 DERBY DIRECTOR: Patricia leathers 300 North "0" Street, 6th Floor, San Bernardino, California 92418 RACE DATE: July 2, 1995 and INTERNATIONAL SOAP BOX DERBY, INC. a not.for.profit corporation organized and existing under the laws of the State of Ohio, having its principal place of business at Derby Downs, Akron, Ohio. WITNESSETH: That, WHEREAS, International Soap Box Derby, Inc. possesses all right, title and interest in and to the name "All.AMERICAN SOAP BOX DERBY," the name "SOAP BOX DERBY" and certain other names associated therewith, as well as all facilities, fixtures, equipment, and other assets heretofore utilized for the promotion and conduct of the All. American Soap Box Derby; and WHEREAS, International Soap Box Derby, Inc. intends to promote and supervise the conduct of the Stock, Super Stock and Masters divisions of the 1995 AIl.American Soap Box Derby; and WHEREAS, licensee desires to conduct Stock, Super Stock and/or Masters divisions of a local Soap Box Derby Race, the winner(s) of which may be eligible to compete in the 1995 AIl.American Soap Box Derby; and WHEREAS, International Soap Box Derby, Inc. is willing to grant licensee the right to utilize the above mentioned names in connection with the running of the local Soap Box Derby competition and to agree that the winner(s) of the Soap Box Derby conducted by licensee shall be entitled to attend and compete in the 199551 All. American Soap Box Derby provided the winner(s} have constructed the winning carls} in accordance with the applicable official rules and the terms and conditions hereinafter set forth have been complied with; NOW, THEREFORE, in consideration of the foregoing, the agreements hereinafter contained and the payment by licensee of a license fee hereinafter provided, it is hereby agreed as follows: A. LICENSEE AND DERBY DIRECTOR AGREE: 1. To conduct and complete, prior to July 9, 1995, the following Soap Box Derby division(s), for which right they shall cause to be paid to International Soap Box Derby, Inc., the amount of $850.00 if one division is to be conducted, $1,100.00 two divisions, or $1.JOG:OO if all three divisions are to be conducted; 117,0'/0.00 STOCK X YES NO SUPER STOCK X YES NO MASTERS X YES NO . 95-1.42 ~'5j) 1995 ALL-AMERICAN SOAP BOX DERBY LICENSE AGREEMENT AGREEMENT, dated this 22nd day of March 1995 between and among: LICENSEE: Rediscover San Bernardino Committee, City of San Bernardino 300 North "0" Street, San Bernardino, California 92418 DERBY DIRECTOR: Patricia leathers 300 North "0" Street, 6th Floor, San Bernardino, California 92418 RACE DATE: July 2, 1995 and INTERNATIONAL SOAP BOX DERBY, INC. a not.for.profit corporation organized and existing under the laws of the State of Ohio, having its principal place of business at Derby Downs, Akron, Ohio. WITNESSETH: That, WHEREAS, International Soap Box Derby, Inc. possesses all right, title and interest in and to the name "All.AMERICAN SOAP BOX DERBY:' the name "SOAP BOX DERBY" and certain other names associated therewith, as well as all facilities, fixtures, equipment, and other assets heretofore utilized for the promotion and conduct of the AIl.American Soap Box Derby; and WHEREAS, International Soap Box Derby, Inc. intends to promote and supervise the conduct of the Stock, Super Stock and Masters divisions of the 1995 All. American Soap Box Derby; and WHEREAS, Licensee desires to conduct Stock, Super Stock and/or Masters divisions of a local Soap Box Derby Race, the winnerls) of which may be eligible to compete in the 1995 AIl.American Soap Box Derby; and WHEREAS, International Soap Box Derby, Inc. is willing to grant Licensee the right to utilize the above mentioned names in connection with the running of the local Soap Box Derby competition and to agree that the winnerlsl of the Soap Box Derby conducted by Licensee shall be entitled to attend and compete in the 199551 All. American Soap Box Derby provided the winner(sl have constructed the winning carls) in accordance with the applicable official rules and the terms and conditions hereinafter set forth have been complied with; NOW, THEREFORE, in consideration of the foregoing, the agreements hereinafter contained and the payment by Licensee of a license fee hereinafter provided, it is hereby agreed as follows: A. LICENSEE AND DERBY DIRECTOR AGREE: 1. To conduct and complete, prior to July 9, 1995, the following Soap Box Derby divisionis!. for which right they shall cause to be paid to International Soap Box Derby, Inc., the amount of $850.00 if one division is to be conducted, $1,100.00 two divisions, or $1,300.00 if all three divisions are to be conducted; STOCK X YES NO SUPER STOCK X YES NO MASTERS X YES NO :J- 1S-I'I2. 2. To conduct the above.designated Soap Box Derby Division(s) in accordance with the Official Rules governing the 1995 All. American Soap Box Derby within the corporation limits of, or adjacent to the city of San Bernardino, California which divisionis) may include entrants from the following cities, counties and/or territories, plus such other and additional entrants as shall be authorized or requested by International Soap Box Derby, Inc. in writing: San Bernardino County, California; 3. To assure that the Derby Director will be and provide satisfactory proof that the Derby Director in fact is physically present in or adjacent to the city of San Bernardino, California during not less than forty (40) weeks within the period from September 3D, 1994 and including August 1, 1995 in order to supervise the conduct of Licensee's Derby program; 4. To meet all deadlines and schedules from time to time established by International Soap Box Derby, Inc. for the performance of acts and the submission of document, information and funds to International Soap Box Derby, Inc.; 5. To have not fewer than ten (10) qualified contestants compete in each division of such local Soap Box Derby, and to provide evidence, at such times as International Soap Box Derby, Inc. may require, of compliance with said requirements, it being understood and agreed that in the conduct of said local Soap Box Derby, Licensee shall not in any manner discriminate against any individual because of race, creed, sex or national origin; 6. At their sole expense, to actively and adequately promote and publicize the local Soap Box Derby in the appropriate geographical area by use of local media and other effective means of publicity and promotion, and to permit the use of Licensee's name and/or establish masthead in Soap Box Derby advertising and promotion by International Soap Box Derby, Inc.; 7 . To refer to the local Soap Box Derby in all advertising and promotion material as the: "San Bernardino Soap Box Derby; II 8. To permit the use of only such advertising and promotional material, when making reference to the local Soap Box Derby, as may serve to promote the success of the AIl.American Soap Box Derby. 9. To secure such approvals and permission from local and state authorities as may be necessary to provide adequate police protection and an ample staff of managing officials to properly conduct the local Soap Box Derby, and to pay any and all expenses incurred in connection with the accomplishment of the foregoing purposes; 1 D. To pay all expenses of the winner(s) of the local Soap Box Derby divisionis) in traveling to and returning from the All. American Soap Box Derby, including without limitation transportation and meals en route, shipping such winner{s} carls) to the AIl.American Soap Box Derby, and any and all other expenses not specifically undertaken herein by International Soap Box Derby, Inc.; 11. To cause the carls I of the winnerls} of its local Soap Box Derby to arrive at Derby Downs, Akron, Ohio not earlier than July 15 and not later than July 23, 1995; and to have winning boyls) and/or girl Is} arrive in Akron, Ohio not later than 12:00 noon, Monday, July 31, 1995; 3 tl{-/'f2 12. At licensee's sole expense, to cause the winner(s) of its local Soap Box Derby to be accompanied by an adult escort at all times other than between the winners' arrival in Akron, Dhio as aforesaid and the conclusion of the 1995 All. American Soap Box Derby; and 13. To furnish to International Soap Box Derby, Inc. on or before July 22, 1995 a certificate or certificates in the form provided by International Soap Box Derby, Inc., certifying that, to the best of the knowledge and belief of the licensee and Derby Director, the winning carls) in the licensee's Soap Box Derby race was/were constructed by the winning contestant(s) in all respects in accordance with the Dfficial Rules governing the 1995 AII.American Soap Box Derby, and certifying further as to the birthdate(s) of the winning contestant(s). B. INTERNATIONAL SOAP BOX DERBY, INC. AGREES: 1. To make available at no expense to licensee and Derby Director, Dfficial Rule Books and such other literature as may be deemed necessary; 2. To hold and conduct the 1995 AII.American Soap Box Derby at Akron, Dhio in which the winner(sl of the official local Soap Box Derby and the winners of other local Derby races provided each such winner has properly qualified for participation, will compete for trophies, scholarships and awards to be furnished by it at no additional expense to the licensee; 3. To establish and maintain headquarters for the 1995 All-American Soap Box Derby in Akron, Dhio and to handle all details in connection with the race, while at no time discriminating against any individuals because of race, creed, color, sex or national origin; and 4. To obtain and maintain in effect a policy or policies of general liability insurance with a company or companies selected by International Soap Box Derby, Inc. in its sole discretion, covering general liability and participants' activities connected with the local Soap Box Derby and the AII.American Soap Box Derby, and to furnish to licensee a certificate evidencing such coverage. This insurance coverage shall include limited accident coverage for each participant in the local race and for any such participant while participating in the AII.American Soap Box Derby activities during a maximum of 48 hours before or after said AII.American Soap Box Derby pre. race week and race and related activities beginning and ending in Akron, Dhio. The above statements do not add to or alter the actual policy or policies provisions as stated herein. C. IT IS AGREED THAT: 1. As a condition precedent to the participation in the 1995 All. American Soap Box Derby by the winner(s} of the local Soap Box Derby conducted by the licensee, such winner(s), together with the carls) of such winner(s}, shall have undergone and passed an inspection conducted at Akron, Ohio by representatives chosen in the sole and absolute discretion of International Soap Box Derby, Inc. Such inspection shall be conducted in accordance with the rules and regulations set forth in the Official Rule Book for the 1995 All. American Soap Box Derby, it being understood and agreed that the decisions of International Soap Box Derby, Inc. officials regarding qualification and/or disqualification of cars and/or the winner(s} shall be final. and will be respected by licensee, the Derby Director and others associated with licensee. 2. All of the winning cars in the local Soap Box Derby races entered in the AII.American Soap Box 'I 95-142 . Derby at Akron, Dhio shall automatically become the property of International Soap Box Derby, Inc.; 3. Credentials to officially represent Licensee at the 1995 All. American Soap Box Derby will be furnished to one bona fide representative of Licensee, authorizing representation of Licensee on matters of policy and administration, provided that -the identity of the representative to receive such credentials shall have been furnished to International Soap Box Derby, Inc. on or before July 31, 1995; 4. The expense of the escort (Licensee representative or parents, or both) for the winner{s) of the local Soap Box Derby in traveling to and from, and while at the All. American Soap Box Derby, shall be borne by the escort or Licensee; 5. Licensee may not assign its rights or obligations hereunder without the prior written consent of International Soap Box Derby, Inc.; and 6. In the event Licensee and/or Derby Director fails to comply with the provisions hereof, International Soap Box Derby, Inc. may, at its sole option, cancel this Agreement, whereupon any monies theretofore paid to International Soap Box Derby, Inc. by Licensee and/or Derby Director hereunder shall be forfeited. WITNESS THE EXECUTION HEREOF: x ~M {J}O-!Lk4 !i& f!fhL 6tJ 0anJAo...Jrudun a:'j ~ X (Licensee's Name) By: Tom Minor (print Official's Name) Mayor (Print Official's Title) ---;;;;;~ \ . . L . /u"( (Official's Signaturel X 4 J!t.) (~<<-S-/J'J7S-- International Soap Box Derby, Inc. By: Jeffrey G. lula General Manager X ..f 4'5-1'Iz. -A4~~!il~rp, CERTIFICATE OF INSURANCE DATE {MM/DDiVY} 05/05/95 THIS CERTIFICATE IS ISSUED AS A MATTER OF.INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. _...__.~-~--- COMPANIES AFFORDING COVERAGE PRODUCER BRUNER GOODHUE CXXJKE CRANZ AGENCY INC 544 WHITE POOD DR STE A AKRON OH 44320 COMP/\NY A GREAT AMERICAN INSURED INTERNATIONAL SOAP BOX DERBY INC POBOX 7233 AKRON OH 44306 COMPANY B HARTFORD COMPANY C COMPANY D COVERAGES THiS IS -r:~' C;;:!UIF{ THAT THE POliCIES Of NSU~1MJCE LISTED SHOW H/>.VE BEf":N ISSUED -'-0 THE INSURED ~~^MED ABOVE FOR THE POLICY PERIOD INDICfI-:fT, ~-VnW!TI-ISTANDING ANY REQUIREM~NT, TERM OFl CONDITiON OF ANY CONTRACT OR OTHER DOCUMl:::Nl WITH riESPECT TO WHICH THIS CEfnil-':I-\H \~A,( BE i3SUEO OR MAY PERTAIN, THE INSURAf\ICE Af:FORDED BY THE POLICIES DESCRI8ED HEREiN IS SUBJECT TO ALL THE TERMS, EXCLU~;IONS .\ND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PA!D CLAIMS CO LTR TYpr:: DF INSURANCE POLICY NUMBER POLICY EFFECTIVE: POLICY EXP1RATION DATE (MMiDD/YY)' DATE (MM/DD/YV) LIMITS GENERAL LIABILITY A X COMMl:RCiAL GENE:RAL l.IABiLlTY GLP 7-01-22-01-02 CLAIMS MADE X OCCUR OWW;;;:-l"S & CONT PROT 05/18/95 05/18/96 GENERAL AGGREGATE T$1;Doo, 000-- PRODUCTS-COMP/OP AGG I $ u1 ~-qoq_( 900 PERSONAL & ADV INJURY $ EACH OCCURRENCE $ 1, boo, 000 FIRE DAMAGE (A~y_o~~_I_ireLL~____ MED EX~I~~r~~:_~.:~.~~__.~_$ X Parti~i~ts Liability AUTOMOBILE liABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS BODILY INJURY (PerperSQn) $ BODILY INJURY (Per accident) PROPERTY DAMAGE GARAGE LIABILITY ANY AUTO UMBRELLA FORM OTHER THAN UMBRELLA FORM AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO QNL Y EACH ACCIDENT $ AGGREGATE $ - ---.-....-.--..-..-.--.--. --_._-~._.~-- EACH OCCURRENCE $ AGGREGATE $ $ ---~.._------~--< EXCESS LIABILITY WORKERS COMPENSATION AND EMPLOYERS' LIABILITY STATUTORY LIMITS EACH ACCIDENT THE PROPRIETORi " PARTNERS/EXECUTIVE OFFICERS ARE I -- OTHERu I B Special Risk 45SR750381 Participants 12/01/94 :12/01/95 $250 Dental Limit Accidental 45SR750382 Volunteer 12/01/94 :12/01/95 $5,000 Accidental Death lu_._ __________J!,)LQQ.Qjl,ccident Medical I.D::::F::R=:::-N::Hi::S~::=::~~;:h~~~d:(~~o~~:rs~i\~:~~~~o:~ ! Derby Event to be run on the following dates: iRiJ.gl~tEL:- .[~Y ~L192.5 Tr:i1i.l Run June 25, CERTIFICATE HOLDER INCL $ $ DISEASE - EACH EMPLOYEE $ DISEASE - POLICY LIMIT EXCL !995&JulyJ<-.1~_~_Ra.iIl._ll<l1:e - July 1, 1995 CANCELLATION SAN BERNARDINO SOAP BOX DERBY REDISCDVER SAN BERNARDINO QM.IITTEE CITY OF SAN BERNARDION & ~CW:C DEVELOPMENT AGENCY OF THE CITY OF SAN BERNARDINO 300 NORTH "D" ST ACORD ~(~INO CA 92418 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL ----3U.- DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, I BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY ~.. _. . F ANY _ KIND __UPC:~ THE QMPANY, ITS AGENTS OR REPRESENTATIVES. ; AU ORIZED R SENT , @ACORDCORPORATION 1993 & REP Full Address Name of Local Race Locatlon of Accldent Date and Hour of Accident Type of Accident Injury to escrlptlon 0 Name Participant [ ] InJured Person Volunteer [ ] Spectator (Use separate from for each person) If a Minor, Parent or Guardian Full Address Apparent Age Phone ] Male [ ] Female [ ] Single [ ] Married [ ] Description of Injuries. Nature and Extent Where was Injured Person taken after accident By Whom Name and Address of Attending Physician Name and Address of Hospital III. If Property Damage, give description of damaged property. Nature and Extent Name and Address of Property Owner Phone ( ) Name and Address of Driver (If vehicle or racer involved) Phone ( ) IV. Witnesses; (Provide Full Name - Address and Phone Numbers) V. Description of Accident: Narrative; Give complete account of accident - Cause and how it happened, If Bodily Injured is involved, describe specifically what the person was doing when injured. Use a separate sheet if needed. 7 '15:/0/2 VI. Sketches: Sketch location of accident, show position of buildings, parking, and all objects involved in relation to accident. Indicate position and directions of moving objects. Mark direction; N for North E for East, etc. Date of Report Prepared by ( Title) Phone Signature Was Accident Reported to anyone via phone? If so, to whom? When? INSTRUCTIONS FOR PREPARATION OF REPORT 1. Preparation: Prepare this report immediately upon occurrence of any accident, injury or damage to property. 2. Attachments: Attach all available statements of witness (Particularly Local Police reports), additional charts, diagrams, or photographs which will aid in review of this report 3. Mail Report: The report should be completed and placed in the mail as soon as possible. If there is going to be a delay of more than 48 hours call what details you have to the following INTERNATIONAL SOAP BOX DERBY, INC. P.O. Box 7233 Akron, OH 44306 Phone 216-733-8723 Fax 216-7331370 DGCC '1;'01 B .A.~fm.., . CERTIFICATE OF INSURANCE I I DATE (MMIDD/YV) PRODUCER .THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE COMPANY A INSURED COMPANY B COMPANY C COMPANY D COVERAGES THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I POLlCY EFFECTIVE POLICY EXPIRATION I DATE (MMIDDIVV) D'~,T!OJ~M/I?DIYY) co , LTR i GENERAL LIABILITY i CO~MERCIAL GENERAL LIABILITY I r: .;." , CLAIMS MADE OCCUR , OWNER'S & CONT PROT I h.uc. , . TYPE OF INSURANCE POLICY NUMBER LIMITS ! :> " 1 I PRODUCTS-COM PlOP AGG $ 1 J , , ,.--.---..--' I , , /'jl GENERAL AGGREGATE ,.s.". PERSONAL & ADV INJURY EACH OCCURRENCE -'[ ,- .> I FIRE DAMAGE (Anyone fire) : MED EXP (Anyone person) AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS i .// ."'....i '1/ i COMBINED SINGLE LIMIT I , BODILY INJURY (Per person) $ BODILY INJURY {Per accident) , PROPERTY DAMAGE $ GARAGE LIABILITY I ANY AUTO AUTO ONLY. EA ACCIDENT $ OTHER THAN AUTO ONLY' i EXCESS LIABILITY , . , ' UMBRELLA FORM OTHER THAN UMBRELLA FORM WORKERS COMPENSATION AND EMPLOYERS' LIABILITY I THE PROPRIETOR/ : PARTNERS/EXECUTIVE I OFFICERS ARE OTHER EACH ACCIDENT i $ AGGREGATE $ 'EACH OCCURRENCE $ AGGREGATE 1$ , ~, STATUTORY LIMITS EACH ACCIDENT i $ DISEASE. POLICY LIMIT $ DISEASE - EACH EMPLOYEE $ '~L:;":, ,1.- ":7;r(::d1 Ptccticip.-3.rf ~j ,1~:;.'-~;.:"!~(jJL;2 'VoluntG3r 12, ji. '; '; 12, '1 L~ 'rl -,~:).CI-ChJ.. y.' I.' ),--,- i :'.::-::,~;i:;;::::i.t~,'.,U_ , - ., ;:.i ,; tiJO T,,-c~-~i L:n..:':' ~.l :}c.,~'.L: DESCRIPTION OF OPERATlONSILOCATIONSIVEHICLESISPECIAL ITEMS CertifiCA""lte hol.-l-:.:: .r ,}k:':;'.~::d l i'~'Oll("j:.: .. . - 'j . . 1 '~(H-3(~j~f .3r.x)1100rnhij":lr'j)i:;(. -yf1:~(.J r, ~ 'on.;: ;};l:"}'j :,;\'~:~nt tn y. ;:tLl ()~l W;'! c.llo'.Jing dates: /' ,/...",ll.. t~ 'ii' ,_I" '11 ?r: r (i- <., .i'ji'l\) :::;"! \<'..;_.!Lc::;1 :,'l} '};:,~ >li ~ '.'.i "' '.J._ .-'. .;; "L~.L J_-L';;':(:-":~ ,'':.:j tCi t__':t~ ''..!i .\:'l-~Ci~;:l~-' ,:_}. ,-.-,'......-:""\ .........., d CANCELLATION );;-- ;, '")l-, ~ TJ" '.7 ; CERTIFICATE HOLDER i'::-'r';:-_~_)::.- ":~. "~.' "\~; .'~' '! ,:? '. !,:.' (.J:'k'Y rye' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN NOTICE TO THE CERTiFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY COMPANY, ITS AGENTS OR REPRESENTATIVES. ,_;:.:..T'_~:_~;i :" T..:\:-'_' )1;1.') .'..:~Y"\r: ) ):: : :;!:HSU,)\h;;~ ;;;~' -..... 'c;.~.')I' ~l:n. ~~W ;1) c'a:;n':lI'.:'II., ~~: XXXl(J"-IIC ..'._'.:' oJ. ,.-"-""; ,j;~,:_:,-, :;(~:''.) lI'Y-: :.'\.::' Y<<';I-1.:~,,)I;<(!'\ @ACORD CORPORATION 1993 j Cj ".'!i:\T/: . ACORD 2SiSl3193},~NAIIDmO CA n41 tl .- REPORT OF ACCIIIENT . Name of Local Race Full Address Locatlon of Accldent Date and Hour of Accident Type of Accident Injury to Participant [ ] Volunteer [ ] Spectator [ ] Property [ ] I. Descrlptlon of Injured Person (Use separate from for each person) Name If a Minor, Parent or Guardian Full Address Phone ( ) - Apparent Age [ ] Male [ ] Female [ ] Single [ ] Married [ ] Description of Injuries. Nature and Extent Where was Injured Person taken after accident By Whom Name and Address of Attending Physician Name and Address of Hospital III. If Property Damage, glve description of damaged property. Nature and Extent Name and Address of Property Owner Phone ( ) - Name and Address of Driver (If vehicle or racer involved) Phone ( ) - .. IV. Witnesses: (Provide Full Name - Address and Phone Numbers) V. Description of Accident: Narrative; Give complete account of accident - Cause and how it happened, If Bodily Injured is involved, describe specifically what the person was doing when injured. Use a separate sheet if needed. I ! I I !