HomeMy WebLinkAboutIowa Department of Transportation-10/8/2012 (2)October 1, 2012
City of Waterloo
Attn: City Clerk
715 Mulberry Street
Waterloo, IA 50703
FIVE STAR SNOW TRAILS
ASSOCIATION, INC
1314 Washington S4 Cedar Falls, IA 50613-4153
Phone: 319-266-0445 0 Cell: 319-231-0819 0 email: damelick@cfu.net
Enclosed for your consideration is the Application to the Iowa Department of Transportation (IDOT)
for renewal of the permit to establish and sign a snowmobile trail within the right-of-way of state
highways. A portion of that trail resides within the city limits of Waterloo. The IDOT requires that
each affected city approve the application before being processed by the Department. Page hof
the application has a block for the signature of the responsible individual representing Waterloo.
PLEASE USE THIS PAGE FOR THE CITY SIGNATURE. DO NOT COMPLETE THE
SIMILAR SECTION -SHOWN ON PAGE- I OF= PLICATION.
Permits are issued for one season only and must be renewed each year. This application is the same
as the one which was approved last year for the city of Waterloo. Items 1, 2, 8, 9 on page 4, items
#17,18,19, 20 on page 5 and items #21, and 22 on page 6 are the only items which affect Waterloo.
Please note the temporary suspension of the trail leaving George Wyth park .
If you have any questions concerning the application and related paperwork, you may contact me at:
319-231-0819(Cell) or e-mail to: damelick@cfu.net
I would appreciate it very much if city action could be taken at the October 10th Council meeting,
if Council action is required. The IDOT is short on staff and it could take them some time to take
their action, so it is imperative that we get the application in their hands as soon as possible, so as
to beat the freezing temperatures and first snowfall with signing of the trail.
Please return to me in the enclosed, "postage applied" envelope as soon as possible after action has
been taken by city officials.
Thank you for your assistance with this matter.
Sincerely,
eka2 I4'21 -4/14 -
Dick Melick
Five Star Snow Trails Assoc., Inc
Administrative Advisor
Iowa Department of Transportation
Form 810028 (02-11)
FOR DEPARTMENT USE ONLY
Permit Number
Application to Perform Work Within State ighway
Right -of -Way
Highway Number
(SEE ATTACHED LISTING)
County
Black Hawk
DOT Project Number
N/A
Expiration/Completion Date
4/15/2013
APPLICANT (INDIVIDUAL OR COMPANY
ASSISTANCE FROM DEPA
First Name
Richard
Middle Initial
C
Last Name
Melick
Phone Number
(319) 231-0819
Company Name
Five Star Snow Trails Association
Phone Number
(319) 231-0819
Street Address
1314 Washington St
City/Town
Cedar Falls
State
IA
Zip Code
50613-4153
WORK TO ,= E ACCOMPLISHED
Approval is hereby requested to enter within the state right of way and to complete the proposed work as detailed
on the attachments and further described as follows:
Snowmobile Trail and Trail Crossing locations as indicated on the attached listing.
Trail is located partially within the city limits of Dunkerton and Waterloo.
All crossisngs shall go into effect after all signs along the highway have been installed by DOT Forces.
All signs placed on Row by applicant shall be removed by applicant.
and shall be located as shown on the detailed plan attached hereto. (See current Iowa Department of
Transportation Utility Accornondation Policy for submittal of detailed plan requirements)
WORK SITE LOCATION
SEE ATTACHED LISTING
The proposed work as described above is located in Section , Twp.
Range
(direction) from
on Highway No.
specifically located as being from
to
generally located
(miles)
(city, county line or other land line). Work proposed is more
(Milepost##) and
(Highway Station)
(Milepost#) and (Highway Station) on the side of highway.
Applicant Signature and Agreement
The undersigned have read the stipulations of this permit agreement as stated as well as attachments which may be included
and by signing this application agree to abide by all stipulations and to complete the work as proposed in compliance with the
stipulations and attachments within one year from the date Department approval is received for said request. Failure on the
part of the applicant to abide by the stipulations or to construct the work desired as stipulated and within the time frame stated
shall render this agreement and request null and void. The undersigned also agrees to save harmless the State of Iowa and
the Iowa Department of Transportation from any damage or fosses that may be sustained by any person or persons on
account of the conditions and requirements of this agreement.
Applicant Name (First, M.l., Last—Print or Type)
Richard C. Melick
Applicant Signature (Handwritten)
Date
9/28/2012
CITY ACTION (IF PROPOSED WORK IS WITHIN AN INCORPORATED CITY, CITY ACTION ACTION IS REQUIRED)
"The undersigned city joins in the grants embodied in the above permit executed by the Iowa Department of Transportation
on condition that all of the covenants and undertakings therein running to the Iowa Department of Transportation shall inure
to the benefit of the undersigned city and recommends action on said permit application as noted below by the delegated city
official".
Recommend Approval
Auth. City O'° dal Signature
(Handwritten)
Do Not Recommend Approval
None Required
Title
(See Attached City Action Sheets)
Date
Name of Authorized City Official (Print or Type)
(SEE ATTACKED CITY ACTION SHEETS)
Authorized City Official for the City of
(SEE ATTACHED CITY ACTION SHEETS)
FEDERAL HIGHWAY ADMINISTRATION ACTION
(DEPARTMENT REPRESENTATIVES WILL REVIEW THE REQUEST AND OBTAIN FHWA ACTION, WHEN NECESSARY)
1 Recommend Approval Do Not Recommend Approval I I None Required
Authorized FHWA Representative Signature
Date
(DOT Final Action & Agreements on next page)
Page 1 of 2
DEPARTMENT OF TRANSPORTATION FINAL ACTION
lI
Application Approved
Application Denied
Permit Number
Authorized Highway District Representative
(Type or Print): DAVE RAMIREZ. EOT
Signature
Date
Notice of intention to commence activities on the highway rights-of-way shall be submitted by the appl'cant a minimum of
48 hours prior to actually commencing the activities as herein granted by this approved application. Notice is to be given to
the following Iowa Department of Transportation representative:
Local DOT Contact Person (Type or Print Name)
DOUG LICK'I'bIG. GARAGE SUPERVISOR
Phone Number
(319) 233-3055
Street Address
1875 EAST RIDGEWAY AVE. PO BOX 1888
C ity/Town
WA'T'ERLOO
State
Lk
ZIP Code
50704
AGREEMENTS
The applicant agrees that if granted a permit to do said work the following stipulations shall govern.
1. The applicant shall carry on the construction, repair, and maintenance with serious regard to the safety of the traveling
public and adjacent property owners and shall save the State and the Iowa Department of Transportation harmless of any
damage or losses that may be sustained by the traveling public on account of such construction, repair, or maintenance
operations.
2. The applicant shall indemnify and save harmless the State of Iowa, its agencies, and employees, from any and alt causes
or actions, suits at law or in equity, for losses, damages, claims, or demands, and from any and alt liability and expense of
whatsoever nature, arising out of or in connection with the applicant's use or occupancy of the public highway.
3. The applicant shall hold the State and the Iowa Department of Transportation harmless of any damage that may result to
said highway because of the construction or maintenance of the facility, and shall reimburse the State or the lowa
Department of Transportation for any expenditures that the State of lowa or the Iowa Department of Transportation may have
to make on said highway rights-of-way on account of said applicant's construction or maintenance activity or lack thereof.
4. Traffic protection shall be in accordance with Part VI of the current Manual on Uniform Traffic Control Devices for Streets
and Highways. The applicant shall be responsible for correctly using signs as needed while work is in progress. Flagging
operations are the responsibility of the applicant.
5. Before beginning any work within the highway rights-of-way, it is the responsibility of the applicant to contact utility
companies whose installations may be affected or encountered. Contact should be made at 1-800-292-8989, a minimum of
48 hours in advance of starting construction. If the work requested in this application should cause a need to relocate or
modify an existing utility, any cost associated shall be as negotiated between the applicant and the utility owner.
6. A copy of the approved application shall be available on the job site at all times for examination by Department of
Transportation officials.
7. The applicant shall seed and mulch all disturbed areas within the highway right-of-way and shall be responsible for the
vegetative cover until it becomes well established. Any surfaced areas such as driveways or shoulders and sodded
waterways and plantings which are disturbed shall be restored to their original condition.
8. If the proposed work results in a pool of water on the applicant's property, this pool of water will be exclusively owned,
controlled, and maintained by the applicant. That part of the modification located on highway right-of-way will be maintained
by the Iowa Department of Transportation for road purposes only.
9. The applicant shall maintain any drainage structure built within the right-of-way that is built for the benefit of the applicant
and not necessary for highway use.
10. This permit is subject to any laws now in effect as well as any new laws which may be hereafter enacted and all
applicable rules and regulations of local, state, and federal agencies.
11. This permit is subject to all the rules and regulations of the Iowa Department of Transportation, and to revocation by the
Iowa Department of Transportation at any time and at no cost to the Department, when in the judgment of the Department it is
necessary in the improvement or maintenance of the highway or for other reasonable cause.
12. The applicant agrees to give the Iowa Department of Transportation 48 hours notice of intention to start construction or
perform maintenance on the highway right-of-way. Any modification to the proposed work shall be approved by the
Department prior to making the change.
13. Unless specifically noted in item #15, all work performed within the right-of-way shall be restricted to a time frame of 30
minutes after sunrise to 30 minutes before sunset.
14. After November 24, 2008, all personnel in the highway right-of-way shall wear ANSI 107 Class 2 apparel at all times
when exposed to traffic or construction equipment.
15. All proposed work covered by this permit shall be at the applicant's expense. The applicant shall reimburse th
Iowa Department of Transportation for any materials removed from the highway right-of-way described as follows:
16. The following special requirements shall apply to this permit:
PLEASE NOTE: The sponsor agrees tohold harmless the State of Iowa and the Iowa Department of
Transportation and to indemnify them from any claim. demand or action by or on behalf of any person or entity.
arising out of or in connection with anything having to do with the sno«nnopbile route. including, but not limited
to. its establishment. construction. use. maintenance. sig ling. cofiguration or existence.
Disclosure Statement The information furnished on this form will be used by the Department of Transportation to determine
approval or denial of the application. Failure to provide all information will result in denial of the application. Information furnished
is public information and copies may be provided to the public upon request.
Page 2 of 2
CITY ACTION (IF PROPOSED WORK IS WITHIN AN INCORPORATED CITY, CITY ACTION IS REQUIRED)
'The undersigned city joins in the grants embodied in the above permit executed by the Iowa Department of Transportation
on condition that all of the covenants and undertakings therein running to the Iowa Department of Transportation shall inure
to the benefit of the undersigned city and recommends action on said permit application as noted below by the delegated city
official".
LS' I eccmmend Approval
0 Do Not Recommend Approval 0 None Required
A City Official i etoare
(H- dwr�ifen)
Title
!e
a 6-{
Date
it 1,(,„,, -
ute7
iirne of Aat orued City Official (Print
lAVl. 5. 0.1 cut-
or type)
Authorized City Official for the City of
WATERLOO
3A
IOWA DEPARTMENT OF TRANSPORTATION
ION
Application to perform work within State °. ighway Right -of -Way
FIVE STAR SNOW TRA1.S ASSOCIATION
Snowmobile Trail and Crossing Locations -Black Hawk County
1. Crossing of US 218 in Waterloo at Marigold Dr, milepost 176.84.
2. Marked, "ungroomed" trail along both ditches of US 218 from Marigold Dr in Waterloo,
milepost 176.84, to bridge at the north Washburn city limits.
3. Crossing under US 218 by way of bridge at north Washburn city limits, milepost 175.58
(NO SIGNING REQUIRED ON ROADWAY)
4. Marked "ungroomed trail along east ditch only of US 218 from bridge listed in item # 3 to
farm driveway approx 300 ft north of Mashburn city limits and immediately north of residence
with street number 6605.
5. Marked, "groomed" trail along east ditch only, of US 218 from the convenience store at 7112
LaPorte Road in Washburn to East Schrock Road, southeast of Washburn.
6. Crossing of US 218 at East Schrock Road, milepost 173.74.
7. Marked, "groomed" trail along both ditches of US 218 from East Schrock Road, milepost
173.74 to LaPorte City north city limits.
8. * This item is completely removed.
9. * This item is completely removed.
10. Crossing of US 218 at County C57 north of Cedar Falls. Stop signs will be placed along the
trail on both sides ofthe highway requiring snowmobiles to stop prior to crossing the first two
lanes and also in the median to require snowmobiles to stop before crossing the next 2 lanes.
milepost 192.88.
11. This item is completely removed.
12. * * * This item number is listed to avoid re -numbering the balance of items .
Black Hawk County-2O12.wpd 4
IOWA DEPARTMENT OF TRANSPORTATION
Application to perform work within State Highway Right -of -Way
FIVE STAR SNOW TRAILS ASSOCIATION (Cont'd)
Snowmobile Trail and Crossing Locations -Black Hawk County (Cont'd)
13. Crossing of I-380/US 20 at intersection with County V49. Club will install signs to direct
Groomer and snowmobiles to cross over I-380 & US 20 on the overpass bridge and not cross
at grade. "No Snowmobiling" signs will be placed along the on and off ramps on both sides
of the freeway. Trail marker signs will be installed along the bridge deck, milepost 66.52.
13A. Along IA 281, trail exits private property via farm field driveway approx 150 ft west of bridge
over creek. Milepost 21.61
13 B. The trail then proceeds east along shoulder to cross bridge, then along shoulder approx 150
ft east of bridge to farm field driveway where it enters private property again. This location
is approx halfway between Goeller Road & Black Hawk Buchanan Road(County V62).
Milepost 21.72
14. Crossing of IA 281 at the alley between Main St and Sycamore St in Dunkerton.
Milepost 13.75
15. Crossing of IA 281 at the Kwik Star Convenience Store at the south edge of Dunkerton.
Milepost 13.27
15A. Crossing IA 28 l (Independence Ave) east of Waterloo, approximately .90 of a mile east of
intersection with County V43 (Elk Run Road) & approximately .10 of a mile east of property
address 4914, immediately east of the blue "Litter Removal" sign, where trail uses field
driveways on either side of the highway, milepost 4.63.
16. Crossing of IA 281 at County C57, milepost 16.64
17. Marked, "ungroomed" trail along both ditches of US 63 from Hudson city limits north to
milepost 158.04, south of US 20 interchange.
18. Crossing of US 63 south of interchange with US 20 at milepost 158.04.
19. Marked, "ungroomed" trail along west ditch only ofUS 63 in Waterloo from milepost 158.04,
crossing under US 20, and proceeding north to Ridgeway Ave.
20. Crossing of US 63 at Ridgeway Ave in Waterloo, milepost 159.58.
1lack 11aoak Count y-20 1 2. wpd 5
IOWA DEPARTMENT OF TRANSPORTATION
Application to perform work within State Highway Right -of -Way
FIVE STAR SNOW TRAILS ASSOCIATION (Cont'd)
Snowmobile Trail and Crossing Locations -Black Hawk County (Cont'd)
21. Marked, "ungroomed" trail along the east ditch only of US 63 from Ridgeway Ave in
Waterloo, milepost 159.58, south approx 500 feet to the parking lot of Heartland Inn Motel.
Trail will end at that point.
22. Crossing of US 63 at Airline Highway in Waterloo, milepost 166.71.
23. Crossing of US 63 approx .25 miles north of West Bennington Rd and approx 170 feet north
of the small green highway milemarker 171. This location is a highway "turn -around) with
farm field driveways coming directly from both the east and west farm fields, milepost 171.03.
* Item 8 and 9 are removed due to temporary suspension of the trail leaving George Wyth State Park
due to development in the area. The trail will be re -opened when an alternative route is developed.
** Item 11 is completely removed due to highway Construction in the Janesville area. A separate
permit application will be prepared to cover the Janesville area when highway construction is
completed if required.
* * * Item 12 is reworded from the 2011 application & retained to avoid re -numbering remaining items.
All other locations shown on this application are the same as listed on the 2011 application.
Note: Marked, "groomed" trail indicates that a track driven motorized trail grooming tractor pulling
a snow drag will be operating to prepare the trail for snowmobile use and special signs applicable to
snowmobile trails will be installed.
Note: Liability insurance for the Five Star Snow Trails Association is covered on page 4 of the
"Land Owners as Additional Insureds" page on the enclosed Certificate of Insurance for the Sno
Hawks Snowmobile Club. All towns involved and the Iowa Department of Transportation are
covered by the additional insured listed as "THE STATE OF IOWA AND ALL OF ITS POLITICAL
SUBDIVISIONS".
Note: A copy of the Insurance for the Sno Hawks Snowmobile Club for the current year is enclosed.
Insurance renewal for year 12-1-2012 to 12-1-2013 is in process. Policy has not yet been issued.
A copy of the approved policy will be provided to each entity involved upon receipt of the policy,
which is expected to be sometime during the month of November 2012.
Black Ilawk County-2012.wpd 6
IOWA DEPARTMENT OF TRANSPORTATION
Application to perform work within State Highway Right -of -Way
FIVE STAR SNOW TRAILS ASSOCIATION
Snowmobile Trail and Crossing Locations -Black Hawk County
1. Crossing of US 218 in Waterloo at Marigold Dr, milepost 176.84.
2. Marked, "ungroomed" trail along both ditches of US 218 from Marigold Dr in Waterloo,
milepost 176.84, to bridge at the north Washburn city limits.
3. Crossing under US 218 by way of bridge at north Washburn city limits, milepost 175.58
(NO SIGNING REQUIRED ON ROADWAY)
4. Marked "ungroomed trail along east ditch only of US 218 from bridge listed in item # 3 to
farm driveway approx 300 ft north oMashbum city limits and immediately north of residence
with street number 6605.
5. Marked, "groomed" trail along east ditch only, of US 218 from the convenience store at 7112
LaPorte Road in Washburn to East Schrock Road, southeast of Washburn.
6. Crossing of US 218 at East Schrock Road, milepost 173.74.
7 Marked, "groomed" trail along both ditches of US 218 from East Schrock Road, milepost
173.74 to LaPorte City north city limits.
8. * This item is completely removed.
9. * This item is completely removed.
10. Crossing of US 218 at County C57 north of Cedar Falls. Stop signs will be placed along the
trail on both sides of the highway requiring snowmobiles to stop prior to crossing the first two
lanes and also in the median to require snowmobiles to stop before crossing the next 2 lanes.
milepost 192.88.
11.This item is completely removed.
12. * * * This item number is listed to avoid re -numbering the balance of items .
Black Hawk County-2012.wpd 4
IOWA DEPARTMENT OF TRANSPORTATION
Application to perform work within State Highway Right -of -Way
FIVE STAR SNOW TRAILS ASSOCIATION (Cont'd)
Snowmobile Trail and Crossing Locations -Black Hawk County (Cont'd)
13. Crossing of 1-380/US 20 at intersection with County V49. Club will install signs to direct
Groomer and snowmobiles to cross over I-380 & US 20 on the overpass bridge and not cross
at grade. "No Snowmobiling" signs will be placed along the on and off ramps on both sides
of the freeway. Trail marker signs will be installed along the bridge deck, milepost 66.52.
13A. Along IA 281, trail exits private property via farm field driveway approx 150 ft west of bridge
over creek. Milepost 21.61
13B. The trail then proceeds east along shoulder to cross bridge, then along shoulder approx 150
ft east of bridge to farm field driveway where it enters private property again. This location
is approx halfway between Goeller Road & Black Hawk Buchanan Road(County V62).
Milepost 21.72
14. Crossing of IA 281 at the alley between Main St and Sycamore St in Dunkerton.
Milepost 13.75
15. Crossing of IA 281 at the Kwik Star Convenience Store at the south edge of Dunkerton.
Milepost 13.27
15A. Crossing IA 281 (Independence Ave) east of Waterloo, approximately .90 of a mile east of
intersection with County V43 (Elk Run Road) & approximately .10 of a mile east of property
address 4914, immediately east of the blue "Litter Removal" sign, where trail uses field
driveways on either side of the highway, milepost 4.63.
16. Crossing of IA 281 at County C57, milepost 16.64
17. Marked, "ungroomed" trail along both ditches of US 63 from Hudson city limits north to
milepost 158.04, south of US 20 interchange.
18. Crossing of US 63 south of interchange with US 20 at milepost 158.04.
19. Marked, "ungroomed" trail along west ditch only ofUS 63 in Waterloo from milepost 158.04,
crossing under US 20, and proceeding north to Ridgeway Ave.
20. Crossing of US 63 at Ridgeway Ave in Waterloo, milepost 159.58.
111ark 1 lawk (buttly-2012.w1x1
5
IOWA DEPARTMENT OF TRANSPORTATION
Application to perform work within State Highway Right -of -Way
FIVE STAR SNOW TRAILS ASSOCIATION (Cont'd)
Snowmobile Trail and Crossing Locations -Black Hawk County (Cont'd)
21. Marked, "ungroomed" trail along the east ditch only of US 63 from Ridgeway Ave in
Waterloo, milepost 159.58, south approx 500 feet to the parking lot of Heartland Inn Motel.
Trail will end at that point.
22. Crossing of US 63 at Airline Highway in Waterloo, milepost 166.71.
23. Crossing of US 63 approx .25 miles north of West Bennington Rd and approx 170 feet north
of the small green highway milemarker 171. This location is a highway "turn -around) with
farm field driveways coming directly from both the east and west farm fields, milepost 171.03.
* Item 8 and 9 are removed due to temporary suspension of the trail leaving George Wyth State Park
due to development in the area. The trail will be re -opened when an alternative route is developed.
** Item 11 is completely removed due to highway Construction in the Janesville area. A separate
permit application will be prepared to cover the Janesville area when highway construction is
completed if required.
* * * Item 12 is reworded from the 2011 application & retained to avoid re -numbering remaining items.
All other locations shown on this application are the same as listed on the 2011 application.
Note: Marked, "groomed" trail indicates that a track driven motorized trail grooming tractor pulling
a snow drag will be operating to prepare the trail for snowmobile use and special signs applicable to
snowmobile trails will be installed.
Note: Liability insurance for the Five Star Snow Trails Association is covered on page 4 of the
"Land Owners as Additional Insureds" page on the enclosed Certificate of Insurance for the Sno
Hawks Snowmobile Club. All towns involved and the Iowa Department of Transportation are
covered by the additional insured listed as "THE STATE OF IOWA AND ALL OF ITS POLITICAL
SUBDIVISIONS".
Note: A copy of the Insurance for the Sno Hawks Snowmobile Club for the current year is enclosed.
Insurance renewal for year 12-1-2012 to 12-1-2013 is in process. Policy has not yet been issued.
A copy of the approved policy will be provided to each entity involved upon receipt of the policy,
which is expected to be sometime during the month of November 2012.
Black Hawk County-2012.wpd
6
- 1 .
.�R ® CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD,YYYY)
11/22/2011
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
V & V Insurance Agency, Inc
PO Box 15 9
103 8th St E
Cresco IA 52136-
CONTACT
NAME:
(A/C. NN Eat): (563) 547-2161 FAX
fAjc. No); (563) 547-2045
E-MAIL
ADDRESs: insurance@vandvins.com
INSURER(S) AFFORDING COVERAGE
NAIC a
INsuRERA:Dakota Fire Insurance Company
GENERAL
X
INSURED SNO HAWKS INC.
1314 WASHINGTON ST
CEDAR FALLS IA 50613—
INSURER B :
$
INSURER C :
$
INSURER D :
INSURER E :
CLAIMS -MADE
INSURERF:
OCCUR
REVISION NUMBER:
%.tVY L. IV, VLJ •- -• • ••• ._•••-•--•-------
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.
INSR
LTR
TYPE OF INSURANCE
ADDL
INSR
SUER
WVD
POLICY NUMBER
3D31117
POLICY EFF
IMM/DD/YYYY),
/ /
12/01/201112/01/2012
/ /
/ /
/ /
/ /
/ /
POLICY EXP
(MM/DD/VYYYJ
/ /
/ /
/ /
/ /
/ /
/ /
UMITS
EACH OCCURRENCE
$ 1,000,000
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
DAAEASESGE O(Ea RENTED
$
MED EXP (Any one person)
$
X
CLAIMS -MADE
OCCUR
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$ 1,000,000
PRODUCTS - COMP/OP AGG
$
GEN'L AGGREGATE LIMIT APPLIES PER:
PRO
POLICY IF(:T LOC
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
_
_
SCHEDULED
AUTOS
NON -OWNED
AUTOS
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
UMBRELLA UAB_
EXCESS UAB
OCCUR
CLAIMS -MADE
/ /
/ /
/ /
/ /
/ /
/ /
EACH OCCURRENCE
$
AGGREGATE
$
$
DED
RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
YIN
N 1 A
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
WC - TORY I M
OT H-
ER
E.L. EACH ACCIDENT
$
E.L DISEASE - EA EMPLOYEE
$
E.L DISEASE - POLICY LIMIT
$
/ /
/ 1
/ /
/ /
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
Snowmobile Club and Trail liability insurance, including liability coverage for (1) Groomer and (1) ATV
(used for trail maintenance). Additional insured: See (2) attached sheets. Premise liability coverage
is Excluded on this policy.
ctK I II-IGA I t IULucrc
( ) - ( ) -
(
--------------
. -• ----- - - •- - -
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
- - - - id, A4---6-----
ACORD 25 (2010/05)
INS025 (201005).01
-. All rig h reserved.
The ACORD name and logo are registered marks of ACORD
CLUB NAME; SNO HAWKS, INC.
LANDOWNERS AS ADDITIONAL INSURED FOR.
CLUB CONTRACTED TRAIL USAGE ONLY
61. Mary D. Shining Trust
5311 Hyacinth Drive Unit 64
Cedar Falls, IA 50613-6415
71. Charles Wilmot
2596 Joplin Avenue
Deriver, IA 50622
62. William A. Shining Trust
5311 Hyacinth Drive Unit 64
Cedar Falls, IA 50613-6415
72. Raymond & Pauline Youngblut
6732 LaPorte Road
Waterloo, IA 50706
63. Ronald Steege
9321 Logan Avenue
Waterloo, IA 50703
73. Tim Youngblut
6905 East Washburn Road
Washburn, IA 50706
64. Eugene E. & Jean M. Stokes
8225 Ford Road
Cedar Falls, IA 50613
74. David M. & Nancy J. Zeien
4622 West Cedar Wapsi Road
Cedar Falls, IA 50613
65. Tall Pine Farms, Inc.
7411 North Raymond Road
Dunkerton, IA 50626
66. Michael & Kathy Tellinghuisen
7611 North Union Road
Janesville, IA 50647
75. The State of Iowa & All of its political
Subdivisions
Wallace State Office Building
Des Moines, IA 50319
76. Five Star Snow Trails Association
5912 Aster Lane
Waterloo, IA 50701
67. Clifford R & L. Marcella Trent
8339 Leverscc Road
Cedar Falls, IA 50613
68. Alan & Marilyn Walker
1303 East Bennington Road
Waterloo, IA 50703
69. Washburn BP Store
7305 LaPorte Road
Washburn, IA 50702
77. City of Janesville Iowa
227 Main Street
Janesville, IA 50647
70. Waterloo Industrial Development
10 West 4h Street
Waterloo, IA 5070]
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