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HomeMy WebLinkAboutThe Path/Leila Nurse/Universal Television LLC RECEIVED OCT - 5 2016 Southold Town Clerk APPLICATION FOR FILMING/STILL PHOTOGRAPHY PERMIT NO: Please Print or Type APPLICATION DATE: October 5, 2016 NAME OF APPLICANT: Leila Nurse /Universal Television LLC /"The Path" MAILING ADDRESS: Kaufman Astoria Studios 34-12 36th St, Ste. 301 Astoria 'QTY 11106 PHONE: BUSINESS: 718.706.3544 HOME: 646.509.7294 NAME OF ORGANIZATION/COMPANY: Universal Television LLC/"The Path" MAILING ADDRESS: SAME AS ABOVE PHONE: 646.509.7294 FAX: 718.706.3637 DESCRIBE TYPE OF ACTIVITY (e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.): Television Show/Universal Television LLC —"The Path"—Season 2 DATE(S) AND TIMES) OF PROPOSED FILMING/PHOTOGRAPHY: MondayOctober 17. 2016—Approx. 6:0am until 11:00am PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary) Southold Town Beach—Rocky Point Rocky Point Rd at Aquaview Ave Fast Marion,NY 11939 NAME OF PERSON IN CHARGE AT SITE: Leila Nurse NUMBER OF PERSONS AT LOCATION (cast&crew included): 40 NUMBER AND TYPE OF VECHILES AT LOCATION: (4) 26 ft box trucks, (1) 28 ft prop truck to be parked on the Dead End of Rocky Point Rd at Aquaview Ave TYPE OF SPECIAL EQUIPMENT: Hand Held camera camera monitor. ANY SPECIAL REQUIREMENTS: Request to get an engineer to inspect the stairs entering Rocky Point Beach at Rockv Point Rd. Signature Return to: Southold Town Clerk Southold Town Hall 53095 Main Road P.O. Box 1179 Southold,NY 11971 INDEMNIFICATION AGREEMENT TOWN OF SOUTHOLD FILMING/STILL PHOTOGRAPHY PERMIT The Applicant shall indemnify and hold harmless the Town from and against all suits, claims, demands or actions for any damage and/or injury sustained or alleged to be sustained by any party or parties in connection with the performance of filming or still photography by the Applicant, his employees or agents or any subcontractor and in case of any such action brought against the Town, the applicant shall immediately take charge of and defend the same at his own cost and expense. In addition, the Applicant will name the Town as an additional insured on any applicable policies. 7 SPY Signature Date Leila Nurse Printed name Assistant Location Manager Title ® DATE(MM/DD/YYYY) ,4 o CERTIFICATE OF LIABILITY INSURANCE 10/05/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT; If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Marsh USA Inc. PHONE FAX 1717 Arch Street A/ N Ext: A/C, /C No): Philadelphia,PA 19103-2797 A DRIESS: Attn:NBCU.Certrequest@marsh.com Fax 212-948-5143 INSURER(S)AFFORDING COVERAGE NAIC# 298523-NBCU-CAS-15-16 INSURER A:ACE American Insurance Company 22667 INSURED INSURER B:Indemnity Ins Co Of North America 43575 NBCUniversal Media,LLC a fully owned subsidiary of Comcast Corporation INSURER C:ACE Property And Casualty Ins Co 20699 INSURER D:ACE Fire Underwriters Co 20702 30 Rockefeller Plaza New York,NY 10112 INSURER E:Agri General Insurance Company 42757 INSURER F: 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. INSRADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYV MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY XSL G2739856A 12/01/2015 12/01/2016 EACH OCCURRENCE $ 4,900,000 DAMAGE TED CLAIMS-MADE E OCCUR PREM SES a occurrence) $ 4,900,000 X SIR:$100,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 4,900,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 25,000,000 X POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 6,000,000 JECT OTHER: A AUTOMOBILE LIABILITY ISA H08860099 12/01/2015 12/01/2016 COMBINED SINGLE LIMIT $ 5,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident C X UMBRELLA LIAR X OCCUR XOO G27924840 001 12/01/2015 12/01/2016 EACH OCCURRENCE $ 10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTION$ $ B WORKERS COMPENSATION PE WLR C48591231(AOS) 12/01/2015 12/01/2016 X STATUTE EERH AND EMPLOYERS'LIABILITY 2,000,000 A Y/N WLR 048591243(CA,MA) 12/01/2015 12/01/2016 E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE D OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) SCF 048591267(WI) 12/01/2015 12/01/2016 E.L.DISEASE-EA EMPLOYEE $ 2,000,000 E If yes,describe under WLRC48591279 TN 12/01/2015 12/01/2016 2,000,000 DESCRIPTION OF OPERATIONS below ( ) E.L,DISEASE-POLICY LIMIT $ A Excess Workers Compensation WCUC48591280(WA) 12/01/2015 12/01/2016 Ea Acc/Dis Employee/Dis Policy 2,000,000 7 SIR 5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Show Name: The Path Production Entity: Universal Television LLC Location/Description of Equipment: Filming Location Subject to the terms and conditions,the General,Automobile,and Umbrella Liability Policies include the Certificate Holder as Additional Insured where required by written contract. Please refer to page 2 for additional coverage/certificate holder information. CERTIFICATE HOLDER CANCELLATION Town of Southold 53095 Main Rd SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE P.O.Box 1179 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold,NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 298523 LOC#: Philadelphia ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA Inc. NBCUniversal Media,LLC a fully owned subsidiary of Comcast Corooration POLICY NUMBER 30 Rockefeller Plaza New York,NY 10112 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICIES PROVIDE COVERAGE FOR THE USL&H AND JONES ACT COVERAGE AND"ALL STATES'ENDORSEMENT. TI I:GENERAL LIABILITY POLICY PROVIDES COVERAGE FOR XCU,PRODUCTS/COMPLETED OPERATIONS HAZARD,BROAD FORM PROPERTY DAMAGE,BLANKET CONTRACTUAL,ADVERTISING LIABILITY,INDEPENDENT CONTRACTORS,S17PARATION OF INSUREDS,PERSONAL.INJURY,PREMISES/ONGOING OPERATIONS AND BLANKET ADDITIONAL,INSURED. THE GENERAL LIABILITY AND WORKERS COMPENSATION POLICIES INCLUDE A WAIVER OF SUBROGATION THAT APPLIES TO ANY PERSON OR ORGANIZATION WHERE REQUIRED BY CONTRACT WE ENTER INTO PRIOR TO THE OCCURRENCE OF LOSS, THIS INSURANCE WILL.APPLY AS PRIMARY INSURANCE WHERE.REQUIRED BY CONTRACT,AND ANY OTHER INSURANCE ISSUED TO SUCH ADDITIONAL INSURED SHALL.APPLY AS EXCESS AND NONCONTRIBUTORY INSURANCE. ADDITIONAL.CERTIFICATE HOLDERS INCLUDE: ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD