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PROOF OF INSURANCE (2016) CLOSEDAMERI-9 OP ID: TT E (MMIDDIYYYY) DAT CERTIFICATE OF LIABILITY INSURANCE f I01114116 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 e 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 endorsernent(S),,__ PRODJCER 360-264-2420 ----------- ------- Waller Insurance Inc. 360-254-0806 PHONF I - ----- .L rat 5512 NE 109th Ct. Suite G ,VV •Vancouver, WA 98662 ADDRESS. -------- - - --- . .. ....... Eva Walter AMC # ------- ---- - IN I SUR . ERA American Cas Co of Reading PA 20427C . . .... ................ . . . . ........... . ............ INSURED AMERICAN CHESS INSTITUTE JN� ER 13416 SE Silver Circle INSURFR C - — ---------- . ......... Vancouver, WA 98683 II INSURCR D .............. ... . ....... ........ 11 1-1 . . . ................ ..... INSURER E .. . .. ....... mr_vtz"Vim �NIUIVIOV.Fx- �OVERAGES CERTIFICATE NUMBER*. POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PO 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 POLIC11ES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- . . . ...... ..... . ....... . .. _.. - L - 1­11 1 1� .. ....................... Po ICY EF� POLICY tx'v I LIMITS NSR POLCYNUMBEM MWID01Yyyy". MWIDWYYYY LTR TYPE OF INSURANCE 1,000,( 300 t GENERAL LIABILITY 'EA0H OCCURRENCE . . ........ '15AMAG 9- r.) . . . . ...... .. ..... .... ... . A X COMMERCIALGeNERA1_ X 1_IABiLITY OCCUR X X (4017390864 390864 07101/75 07/01116 MED EXP �Agly one po", CLAIMS-MADE PERSONAL & I,$ 1,000,I: X Business Owners I GENT AGGREGATE LIMIT APPLIES PER: I I I 1 PIRC, I I X POLICY L1.0c AUTOMOBILE LIABILITY ANY AUTO ALL OWNED i SCHEDULED AUTOS j AUTOS I NOW-OWNED i HIRED AUTOS IAUTCS UMBRELLA LIAR I OCCUR EXCESS LIAB CLAIrzs^ MADE WORKERS COMPENSATION J J AND EMPLOYERS LIABILITY Yj N' X 16016676150 071011115 07/01116 A ANY OFFV1,'44NEMI9f:R EXCLUDE,& N/A (Mandotory fil IM) e's� JDsvibe ugldo� ff PIP110N OF rah N_R_AT1qN_§ _b_11111N mm DESCRIPTON OF OPERATIONS � LOCATIONS VC.MCLES I ' mtsch ACORD'101, AdOftnaI Romaolt5 Scimcluta" if more space is re4uired) RE: Chess classes and events. Ef Camino Crook Elementar� School 1 CIW of El Segundo is named as additional insured per the a tacked form $8- I rx -E� 14 9,132-E, Waiver of Subrogation applies per the attached form SB.14632 Workers Comp waiver Of subrogation per WC040306, GENERAL AQ WRLGAI r $ PRODUCTS - C 0 M P 1OP AGG $ BODILY INJURY (Per Person) BODILY INJURY (Per accident) 0"ooFTe,' I VNA iZ�N t '4 OCCURRENCE � $ STATU, WT � �QTH-� W y l'�VUIS � '_L_r'F _', EL EACH ,A ACCIDENT � . . ..... .. - $ E, L DISEASE - FA t�MR,OYFE!' , E - L D .. I .. $ - L, - A . SE'^'P�O'IjC_Y LIMIT l's 0010 1,000 i'000 1A0 LE HOLDER CANCELLATION CITYOEL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of EL Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Eva Waller . _ A, I C - 1988-20 1 10 ACORD CORPORATION. All rights reserved, ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD SB'14G&32-E CNA (Ed. 06/11) Policy #4017390864 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,,,,", BLANKET ADDITIONAL INSURED - LIABILITY EXTENSION This endorsement modifies insurance provided under the following: 8US|NESSOVVNERS LIABILITY COVERAGE FORM Coverage any person or organization covered as an additional insured on any other endorsement now or hereafter attached to this Policy. 1. ADDITIONAL INSURED — BLANKET VENDORS WHO (SAN INSURED |o amended to include aoon additional insured any person or organization (referred to below as vendor) with whom you agreed, because of a written contract oragreement to provide insurance, but only with respect to"bodily or "property damage" arising out of which are distributed or sold in the regular CmUrme of file vendor's business, subject to the following additional exclusions: 1. The insurance afforded the vendor does not apply to: a. "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; b. Any express warranty unauthorized byyou; c Any physical or chemical change in the product made intentionally by the vendor; d. Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the mub-Mitwt|mmof parts under instructions from the monufooturor, and then repackaged in the original uuntainer� o. Any failure to make such inspections, adjustments, tests or �e�onn� as the vendor has agreed to make or mmmmoUy undertakes to make in the usual course of buoineas, in connection With the distribution or sale of the products; f. Demonotra|on, insta||atinn, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale af the product; g. Products which, after distribution or sale by you, have been labeled or relabeled orused an m container, part or ingredient of any other thing or substance by or for the vendor; or SB-14693-E h. hsin out of the sole negligence of the vendor for its own acts or omission or those of its employees or anyone else acting on its behalf. However, this exclusion dmya not apply to: (1) The exceptions contained in Subparagraphs d.nrf.;o, (2) Such inspections, adjustments. tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of buaineoa, in connection with the distribution or sale of the products. 2. This insurance does not apply to any insured pnnsmm or organization, frorn whorn you have oc]Uined such products, or any ingredient, part or oonbm\mer. entering into, accompanying or containing such products. 3. This provision 2. does not apply tn any vendor included as on insured by an endorsement issued byum and made a part mY this Pohcy. 4. This provision 2. does riot apply [f"bodily irjur)(' "property or damage" included within the °pmudumto+osnup|etecf operations hazard" is excluded either by the provisions ofthe Policy or by endorsement. 2. MISCELLANEOUS ADDITIONAL INSUREDS WHO |SAN INSURED ia amended to include ason insured any person or organization (called additi | insured) described in paragraphs 2.a. through 2.h. below whom you are required to add as an additional insured on this policy under a written contract or agreement but the written contract or agreement must be: 1. Currently hmeffect or becoming effective during the term of this policy; and 2. Executed prior to the "bodily injury,"' "property dmmage" or *'personal and odverfising injury," but Only the following persons or organizations are additional insureds under this endorsement and Page 1of5 coverage provided to such additional insureds is limited as provided herein: a. Additional Insured — Your Work That person or organization for whom you do work is an additional insured solely for liability due to your negligence specifically resulting from your work for the additional insured which is the subject of the written contract or written agreement. No coverage applies to liability resulting from the sole negligence of the additional insured. The insurance provided to the additional insured is limited as follows: (1) The Limits of Insurance applicable to the additional insured are those specified in the written contract or written agreement or in the Declarations of this policy, whichever is less. These Limits of Insurance are inclusive of, and not in addition to, the Limits of Insurance shown in the Declarations. (2) The coverage provided to the additional insured by this endorsement and paragraph F.9. of the definition of "insured contract" under Liability and Medical Expenses Definitions do not apply to "bodily injury" or "property damage" arising out of the "products - completed operations hazard" unless required by the written contract or written agreement. (3) The insurance provided to the additional insured does not apply to "bodily injury, "' ""property damage," or "personal and advertising injury" arising out of the rendering or failure to render any professional services. b. State or Political Subdivisions A state or political subdivision subject to the following provisions: (1) This insurance applies only with respect to the following hazards for which the state or political subdivision has issued a permit in connection with premises you own, rent, or control and to which this insurance applies: (a) The existence, maintenance" repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoistaway openings, sidewalk vaults, street banners, or SB- 146932 -E (Ed. 06111) SB- 146932 -E (Ed. 06111) decorations and similar exposures; or (b) The construction, erection, or removal of elevators; or (2) This insurance applies only with respect to operations performed by you or on your behalf for which the state or political subdivision has issued a permit. This insurance does not apply to "bodily injury," "property damage" or "personal and advertising injury" arising out of operations performed for the state or municipality. c. Controlling Interest Any persons or organizations with a controlling interest in you but only with respect to their liability arising out of: (1) Their financial control of you; or (2) Premises they own, maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for such additional insured. d. Managers or Lessors of Premises A manager or lessor of premises but only with respect to liability arising out of the ownership, maintenance or use of that specific part of the premises leased to you and subject to the following additional exclusions: This insurance does not apply to: (1) Any "occurrence" which takes place after you cease to be a tenant in that premises; or (2) Structural alterations, new construction or demolition operations performed by or on behalf of such additional insured. e. Mortgagee, Assignee or Receiver A mortgagee, assignee or receiver but only with respect to their liability as mortgagee, assignee, or receiver and arising out of the ownership, maintenance, or use of a premises by you. This insurance does not apply to structural alterations, new construction or demolition operations performed by or for such additional insured. Page 2 of 5 C�II f. Owners /Other Interests — Land is Leased An owner or other interest from whom land has been leased by you but only with respect to liability arising out of the ownership, maintenance or use of that specific part of the land leased to you and subject to the following additional exclusions: This insurance does not apply to: (1) Any "occurrence" which takes place after you cease to lease that land; or (2) Structural alterations, new construction or demolition operations performed by or on behalf of such additional insured. g. Co -owner of Insured Premises A co -owner of a premises co -owned by you and covered under this insurance but only with respect to the co- owners liability as co- owner of such premises. h. Lessor of Equipment Any person or organization from whom you lease equipment. Such person or organization are insureds only with respect to their liability arising out of the maintenance, operation or use by you of equipment leased to you by such person or organization. A person's or organization's status as an insured under this endorsement ends when their written contract or agreement with you for such leased equipment ends. With respect to the insurance afforded these additional insureds, the following additional exclusions apply: This insurance does not apply: (1) To any "occurrence" which takes place after the equipment lease expires; or (2) To "bodily injury," "property damage" or "personal and advertising injury" arising out of the sole negligence of such additional insured. Any insurance provided to an additional insured designated under paragraphs b. through h, above does not apply to "bodily injury" or "property damage" included within the "products- completed operations hazard." 3. The following is added to Paragraph H. of the BUSINESSOWNERS COMMON POLICY CONDITIONS: H. Other Insurance SB- 146932 -E (Ed. 06/11) SB- 146932 -E (Ed. 06/11) 4. This insurance is excess over any other insurance naming the additional insured as an insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance be either primary or primary and noncontributing. 4. LEGAL LIABILITY — DAMAGE TO PREMISES A. Under B. Exclusions, 1. Applicable to Business Liability Coverage, Exclusion k. Damage To Property, is replaced by the following: k. Damage To Property "Property damage" to: 1. Property you own, rent or occupy, including any costs or expenses incurred by you, or any other person, organization or entity, for repair, replacement, enhancement, restoration or maintenance of such property for any reason, including prevention of injury to a person or damage to another's property; 2. Premises you sell, give away or abandon, if the "property damage" arises out of any part of those premises; 3. Property loaned to you; 4. Personal property in the care, custody or control of the insured; 5. That particular part of any real property on which you or any contractors or subcontractors working directly or indirectly in your behalf are performing operations, if the "property damage" arises out of those operations; or 6. That particular part of any property that must be restored, repaired or replaced because "your work" was incorrectly performed on it. Paragraph 2 of this exclusion does not apply if the premises are "your work" and were never occupied, rented or held for rental by you. Paragraphs 1, 3, and 4, of this exclusion do not apply to "property damage" (other than damage by fire or explosion) to premises: (1) rented to you: Page 3 of 5 T (2) temporarily occupied by you with the permission of the owner, or (3) to the contents of premises rented to you for a period of 7 or fewer consecutive days. A separate limit of insurance applies to Damage To Premises Rented To You as described in Section D — Liability and Medical Expenses Limits of Insurance. Paragraphs 3, 4, 5, and 6 of this exclusion do not apply to liability assumed under a sidetrack agreement. Paragraph 6 of this exclusion does not apply to "property damage" included in the "products- completed operations hazard." B. Under B. Exclusions, 1. Applicable to Business Liability Coverage, the last paragraph of 2. Exclusions is deleted and replaced by the following: Exclusions c, d, e, f, g, h, i, k, I, m, n, and o, do not apply to damage by fire to premises while rented to you or temporarily occupied by you with permission of the owner or to the contents of premises rented to you for a period of 7 or fewer consecutive days. A separate limit of insurance applies to this coverage as described in Section D. Liability And Medical Expenses Limits Of Insurance. C. The first Paragraph under item 5. Damage To Premises Rented To You Limit of Section D. Liability And Medical Expenses Limits Of Insurance is replaced by the following: The most we will pay under Business Liability for damages because of "property damage" to any one premises, while rented to you, or temporarily occupied by you, with the permission of the owner, including contents of such premises rented to you for a period of 7 or fewer consecutive days, is the Damage to Premises Rented to You limit shown in the Declaration. 5. Blanket Waiver of Subrogation We waive any right of recovery we may have against: a. Any person or organization with whom you have a written contract that requires such a waiver. 6. Broad Knowledge of Occurrence The following items are added to E. Businessowners General Liability SB- 146932 -E (Ed. 06/11) SB- 146932 -E (Ed. 06111) Conditions in the Businessowners Liability Coverage Form: e. Paragraphs a. and b. apply to you or to any additional insured only when such "occurrence," offense, claim or "suit' is known to: (1) You or any additional insured that is an individual; (2) Any partner, if you or an additional insured is a partnership; (3) Any manager, if you or an additional insured is a limited liability company; (4) Any "executive officer" or insurance manager, if you or an additional insured is a corporation; (5) Any trustee, if you or an additional insured is a trust; or (6) Any elected or appointed official, if you or an additional insured is a political subdivision or public entity. This paragraph e. applies separately to you and any additional insured. 7. Bodily Injury Section F. Liability and Medical Expenses Definitions, item 3. "Bodily Injury" is deleted and replaced with the following: "Bodily injury" means bodily injury, sickness or disease sustained by a person, including death, humiliation, shock, mental anguish or mental injury by that person at any time which results as a consequence of the bodily injury, sickness or disease. 8. Expanded Personal and Advertising Injury Definition a. The following is added to Section F. Liability and Medical Expenses Definitions, item 14. Personal and Advertising Injury, in the Businessowners General Liability Coverage Form: h. Discrimination or humiliation that results in injury to the feelings or reputation of a natural person, but only if such discrimination or humiliation is: 1. Not done intentionally by or at the direction of: a. The insured; or b. Any "executive officer," director, stockholder, partner, member or manager (if you are a limited liability company) of the insured; and Page 4 of 5 '7 F1, T/'A 2. Not directly or indirectly related to the employment, prospective employment, past erriptoyment or termination of employment of any person or person by any insured. b. The following is added to Exclusions, Section B.: (15)Discrimination Relating to Room, Dwelling or Premises Caused by discrimination directly or indirectly related to the sale, rental, lease or sub -lease or prospective sale, rental, lease or sub -lease of any room, dwelling or premises by or at the direction of any insured. (16)Flnes or Penalties Fines or penalties levied or imposed by a governmental entity because of discrimination. SS- 146932 -E (Ed. 06111) SB- 146932 -E (Ed. 06111) c. This provision (Expanded Personal and Advertising Injury) does not apply if Personal and Advertising Injury Liability is excluded either by the provisions of the Policy or by endorsement. 9. Personal and Advertising Injury Re- defined Section F. Liability and Medical Expenses Definitions, item 14, Personal Advertising Injury, Paragraph c. is replaced by the following: c. The wrongful eviction from, wrongful entry into, or invasion of the right of private occupancy of a room dwelling or premises that a person or organization occupies committed by or on behalf of it's owner, landlord or lessor. Page 5 of 5 April 8, 2015 Statement omitting Auto insurance Liability from City of © Segundo This statement is to confirm that the American Chess Institute does not possess Auto Business Liability insurance. This insurance coverage will not be necessary for the function of the duration of the weeklong summer camps ng place at M Segundo's community center. Jake Steedman Accounts Manager Success Through Chess /Code to the Future (253) 651.3454 b VOMPO M , WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4 -84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -- CALIFORNIA We have the right to recover our payrnents frorn anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule, (This agreement applies only to the extent that you perform work under a written ccintract that requires you to obtain this agreement frorn us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5 of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization THE CITY OF EL SEGUNDO 350 v1AIN STREET EL SEGUNDO, CA 90245 Job Description EDUCATIONAL INSTRUCTOR This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated,. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No, Endorsement No, Insured Premium $ Insurance Company WC 04 03 06 (Ed. 4 -84) Countersigned by