TEANECK BOARD OF EDUCATION 651 Teaneck Road Teaneck, NJ 07666

HOLD HARMLESS AGREEMENT AND CERTIFICATE OF INSURANCE APPLICATION

APPLICANT COMPLETE THREE (3) COPIES: 2 copies to School (1 to be kept by School of Use and I to be forwarded to the Business Office) AND 1 copy to Applicant’s insurance Agent.

The use of Teaneck Public School properties by the below identified organization is expressly contingent upon a certificate of insurance being placed on file with the Teaneck Board of Education School Business Administrator/Board Secretary, 651 Teaneck Road, Teaneck, NJ 07666, PRIOR to the date of first use.

The certificate of insurance must indicate the following:

Evidence of liability coverage at a minimum Combined Single Limit of $1,000,000 per occurrence/$2,000,000 aggregate insuring the Licensee against any liability for bodily injury and property damage underwritten on a primary, non-contributory basis. The Teaneck Board of Education shall be named as an additional insured on all such insurance policies. The Licensee must also include an additional insured endorsement via a CG 20100704 or equivalent. A copy of the necessary insurance policy must be presented to the Licensor, upon request, prior to the Licensee's use of the facilities.

THIS HOLD HARMLESS AGREEMENT MUST BE COMPLETED FOR EVERY ACTIVITY. A COPY SHOULD BE FORWARDED TO YOUR INSURANCE AGENT FOR THE PURPOSE OF OBTAINING A CERTIFICATE OF INSURANCE UNLESS AN IN-FORCE CERTIFICATE IS ALREADY ON FILE WITH THE BUSINESS ADMINISTRATOR/BOARD SECRETARY AND BUILDING PRINCIPAL.

Applicant: Complete the following- PLEASE TYPE OR PRINT

For and in consideration of the renting of the ________________________________________________ (Auditorium, Gym, Student Ctr, etc.)
at _____________________________________ on __________________________________________ (Teaneck Public Schools)	(month)	(day)	(year)

The ________________________________________, including its officers, owners, members, agents, contractors, servants, employees, volunteers, licensees, or invitees (collectively, the “Licensee”) hereby covenants and agrees to save and hold harmless
(Name of Organization)

the Teaneck Board of Education, including its respective officials, commissioners, officers, members, agents, contractors, servants, employees, volunteers, licensees, invitees and assigns (collectively, the “Board”), harmless from and against any and all claims, losses, damages, injuries and expenses arising out of, resulting from, or incurred in connection with Licensee’s use of the Board’s facilities, including but not limited to, the Licensee's use of any portable equipment..

DATE:___________________________ AUTHORIZED SIGNATURE:___________________________

ORGANIZATION:_________________________________ ADDRESS:__________________________