4.11 4.11
RACES&WALKSUeffAurelia5k— 12-16-19
RESOLUTION AUTHORIZING JEFF AURELIA
SCHOLARSHIP FUND 5K ROAD RACE
RESOLUTION NO. 12019
INTRODUCED BY:
WHO MOVED ITS ADOPTION
SECONDED BY:
WHEREAS, the Jeff Aurelia Scholarship Fund has requested authorization from the
Queensbury Town Board to conduct a 5k road race to benefit the Jeff Aurelia Scholarship Fund as
follows:
SPONSOR Jeff Aurelia Scholarship Fund
EVENT 5k Road Race
DATE Wednesday,January 1",2020
TIME 10:00 a.m. — 11:30 a.m. (approximately)
PLACE Beginning and ending at Glens Falls High School
Campus(Letter and map delineating course are attached)
NOW, THEREFORE,BE IT
RESOLVED, that the Queensbury Town Board hereby acknowledges receipt of proper
proof of insurance from the Jeff Aurelia Scholarship Fund and approves the Jeff Aurelia
Scholarship Fund's 5k Road Race partially within the Town of Queensbury to benefit the Jeff
Aurelia Scholarship Fund on Wednesday,January 1", 2020, and
Y
BE IT FURTHER,
RESOLVED, that the Town Board hereby approves this event subject to the Town
Highway Superintendent's approval of the race, which approval may be revoked due to concern for
road conditions at any time up to the date and time of the event.
Duly adopted this 161h day of December, 2019, by the following vote:
AYES
NOES
ABSENT:
011.e e; David Lo'!ell
VV
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TO: TOWN BOARD
FROM: DAVID DUELL
DATE: DECEMBER 11, 2019
RE: Jeff Aurelia Scholarship Fund Big A's 5K Race
I have reviewed the request by the Peter D. Casertino, which will hold their Jeff Aurelia
Scholarship Fund 81q As 5Y Race event on Wednesday January 1, 2020 to benefit College
scholarships for Queensbury and Glens Falls High School Graduates.
Weather permitting, I hereby grant my approval for this event to be held on the following roadway
that is under my jurisdiction: Upper Sherman Ave from Western Ave to Hidden Hill Dr to Oak
Tree Cir, Maple Dr back to Hidden Hill Dr., Dixon Rd to Jerome Ave. The remaining roadways are
not in my jurisdiction and may require additional authorization.
David Duell
Highway Superintendent
Town of Queensbury
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PRINT DATE:!12/12/2019
CERTIFICATE OF INSURANCE ---- ----- -----
CERTIFICATE NUMBER:120191212753128, 1
AGENCY: +�-- ----- -- ------- -
Edgewood Partners Insurance Center THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND j
j 2727 Paces Ferry Road,Building Two,Suite 1500 I CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES
Atlanta,GA 30339 NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
678-324-3300(Phone),678-324-3303(Fax) - - BELOW.
(NAMED INSURED: INSURERS AFFORDING COVERAGE:
USA Track&Field,Inc. The Jeff Aurelia Scholarship Fund
INSURER A:Philadelphia Indemnity Ins.Co.NAIC#:18058
130 East Washington Street,Suite 800 4
Indianapolis IN 46204 INSURER B:Philadelphia Indemnity Ins.Co.NAIC#:19058
EVENT INFORMATION: ---- ---- --------__._.---- _.-- __.-—-----..r
Big As 5K(111/2020-1/2/2020)
(POLICY/COVERAGE INFORMATION:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY
i 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.AGGREGATE
i LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ � a- �__W_ - -•
INS!TYPE OF INSURANCE: -_� !POLICY NUMBER(S):' EFFECTIVE: I EXPIRES:-I LIMITS:
A GENERAL LIABILITY - ----
! X Occurrence IPHPK2060515 {11/1/2019 {11/1/2020 GENERAL AGGREGATE(Applies Per Event) $3,000,000
_ 112:01 AM 112:01 AM
I X Participant Legal Liability I I j j EACH OCCURRENCE �, $1,000,000
- DAMAGE TO RENTED PREMISES(Each Occ.) $1,000,000
1 1 MEDICAL EXPENSE(Any one person) EXCLUDED
i ! i PERSONAL&ADV INJURY $1,000,000
PRODUCTS-COMP/OP AGG _ $3,000,000
i B �UMBRELLA/EXCESS LIABILITY _
i---------- -- -
X Occurrence i PHUB697455 11/1/2019 11/1/2020 1 EACH OCCURRENCE - -$10,000,000
_ 112:01 AM 12:01 AM
AGGREGATE $10AOOA00
i DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS: -
Coverage applies to USA Track& Feld sanctioned events and registered practices, including any directly related activities, such as event set-up and tear down,
participant check-in and award ceremonies.
l
The certificate holder is an additional insured per the following endorsement:Additional Insured-Certificate Holders(Form PI AM-002) !
(
iThe General Liability policy is primary and non-contributory with respect to the negligence of the Named Insureds(Form CG 00 01)
I
The General Liability policy contains a blanket Waiver of Subrogation as required by contract per Waiver of Transfer of Rights of Recovery Against Others(Form CG
2404).
Excess policy follows form of underlying General Liability.
CERTIFICATE HOLDER: NOTICE OF CANCELLATION: --�
— - - -J i Should y of the above described policies be cancelled before the expiration date thereof,
Town of Queensbury notice will be delivered in accordance with the policy provisions.
1 72 Bay Road
Queensbury NY 12804 AUTHORIZED REPRESENTATIVE_ - .-,----_�
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Date Received / / '' `
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Assoc. Sanction#
National Control#
N.O.Signature USATF
For Official Use only
USA TRACK & FIELD SANCTIONED EVENT
REQUEST FOR CERTIFICATE OF LIABILITY INSURANCE
The approved copy of the Application for Sanction serves as the organizer's proof of insurance. Please note that unless insurance is waived,
organizers granted sanctions are automatically added to the USATF liability insurance policy for most activity surrounding the sanctioned event. In
addition,USATF may allow facilities or sponsors to be named as additional insured parties for sanctioned events. An organizer who requires one
or more certificate(s)of insurance for its facilities or sponsors should complete this form. See sanction instructions and insurance brochure for
further information. For more information on the USATF Sanction/Insurance policies visit www.usatf.org/groups/eventdirectors
Complete a separate copy of this form for each party for whom you are requesting a certificate. A fee will be charged for rushed certificates(see late
fee schedule).Return this request to the address listed below.
LATE FEE SCHEDULE RETURN THIS FORM TO:
Less than 5 business days $10 each
Less than 36 hours $25 each
➢Late fees are based on the date received by the National
Office of USATF and the"Date Certificate is Needed"date
EVENT INFORMATION (Type or Print leeiblv!! If it is not legible,the certificate will not be processed or maybe pro ssed into redly)
__. . �!+
Event Name Big A's 5k 1/1 19 � 1.. ,
Date(s)of Event
Event Organizer Tom Aurelia/Peter Casertino
Event Contact Person Mary Lou Aurelia Phone 518-798-0345
Address 19 Northup Drive, Fax n/a
Queensbury NY 1804 E-mail aureliaathome@roadrunner.com
THIRD PARTY INFORMATION
Party Requiring Certificate Town Of Queensbury
Name will appear on the certificate of insurance EXACTLY as listed here
Third Party Contact Person .Joanne Watkins Phone 518-761-8200
Third Party Address 72 Bay Road Fax 518-761-8239
Queensbury, NY 12804 E-mail Joannew@queensburytown.net
Date Certificate is Needed_12/5/2018 (Note:It may take up to 30 days after submission of this form—please plan accordingly.)
DO NOT PUT"ASAP"
OTHER INSURANCE INFORMATION—PLEASE COMPLETE EACH QUESTION
Interest of Third Party: Facility _ Sponsor Governmental Entity '._ Municipality
Is the third party in the business of providing or selling alcohol,food or beverage? Yes O No_Q_
If yes,will they be providing same at the event? Yes 0 No- (If"Yes"the third party must name USATF,its employees,directors,
assigns&USATF Certified Officials as additional insureds to their policy. This certificate must be in hand before USATF will issue a certificate to
this third party.)
Method of Certificate Delivery Send Certificate by%Email or_ Fax
All certificates will be sent to the Event Contact(as listed above)by e-mail(unless specifically indicated above to be sent by fax). The event contact is then required
to forward the certificate to their third party. USATF will no longer send certificates directly to third parties.
Revised 02112