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PROOF OF INSURANCE (2018) CLOSED RK
AM EC H-1 .................................... .P-Lid;_
.✓ �.... DATE(MM/DD/YYYY)
CERTIFICATE OF
LIABILITY INSURANCE Orr
........................................................................................................ ..�. ..................
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(les) must have ADDITIONAL INSURED provisions or 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 ri hts to the certificate holder in lieu of such endorsement(s).
.�................___........................... ...........................m9...._ _..........__..m.........._...... .......................................................................................................__......___._rr_w.
PRODUCER
INC, E Ext):360-354-4 Kelsey 360-3
B own&Brown of WA Inc dba 360 54-44 8 NAME; Elizabeth 488 ��rHX 54-1946
CONTACT
PP
AIC Noi:
P.O.Box 551 E- AIL
LeanneHo mes 64 ( )AFFORDING
y �WA A E :
INSURERS COVERAGE NAICp
INSURER A:Philadelphia Indemnity Ins. 18058
INSURED Code to the Future INSURERB:
American Chess Institute,Inc.
13415 SE Silver Circle INSURER c.
Vancouver,WA 98683 INSURER D:
INSURER E:
INSURER F:
JP9, R.A.^ '. .,rr.,.,.ww__w w__r_,., QF1I3 IF19&D"_!U fERL, REVISIONITl�4j.()FIBER ............................... W
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 'ERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH DOLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
NSR
STYPE OF INSURANCE ADDL'JSUBR' POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LIP IVSD i WV'VD (MMfPP[YYYY) IMM,PPNYYY)„
A X COMMERCIAL GENERAL LIABILITY _EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X) OCCUR X PHPK1639229 04/14/2017 07/01/2018 ETORE'TED 0
I_DAMAGE TO REN'TED
„, S „,
100,00
MED EXP(Any one person) $„ 5,000
; ' " PERSONA,..L.&ADV INJURY $
1,000,000
gTEN ECfR LIMIT AP L , AGGREGATE $
2,000,000
POLICY C2,000,000CILOC PRODUCTSCOMPIOP AGG $
OTHER
A AU`OMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000
(Ea awisl?Lf(),............,,,,,,,, $
ANY AUTO PHPK1639229 04/14/2017 07/01/2018 BODILY,INJURY„(Per„person) $
_
AUTOS ONLY _I AUTOSULED BODILY INJURY(Per accident) $
X HIRED X NON rNED PROPERTY DAMAGE
i. AUTOS ONLY I AUTOS ONLY „(Pgr,accidenO $
A X UMBRELLA LIAR II OCCUR MADE ECH OCCIJRRENCE $ 1,000,000
A
EXCESS LIAB PHUBS80181 04/14/2017 07/01/2018 AGGREGATE $
DED X RETENTION$ 10000i $
PER I
AND
ANY
RIETOR EXCLUDED? [ PHPK1639229 04/14/2017 07/01/2 E EACH ACCIDENT oR H-
A WORKERS COMPENSATION LOYERS'LIABILITY STATUTE F.
Y�Ni ' 018 I $ 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE :NIA
(Mandatory in NH) WA STOP GAP-EMPLOYER LIAB E I_ DISEASE•EA EMPLOYEE $ 1,000,000
If yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS,below E I. DISEASE•POLICY LIMIT $
f '
�ESCR@PTJ” ,C+ yr,[,,RA 'ION"S k gl''A3'1'ON9 k VE"CtF (ACCORD 'Gt AfldltNan� L�Lr q rL u$ e➢yr(g+ ip be attached if more space is required)
enera la I f e UX NT OrSC3men': man eNice0S 1"'ll Ca I.)t I(.l "L
Coveragg,e Includes Claims Made Coverage as follows:
Professional Liability 1 000 0100 Each Occurrencel 2,000,000'Aggrec�'ate
AbuselMolestation 1,06,060 Each Occurrencel 2,000,000 Aggrega e
CERTIFICATE HOLDER CANCELL. A' ION
.............T........
.............
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
EI Segundo Recreation
Department
300 East Pine Avenue ^AUTHORIZED REPRESENTATIVE._............................................. .�..
EI Segundo, CA 90245 4arv, 4P,J
ACORD 25(2016/03) ©1988-2015 ACORDmCORPORAT
ION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
PI-GLD-HS (10/11)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
GENERAL LIABILITY DELUXE ENDORSEMENT:
HUMAN SERVICES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
It is understood and agreed that the following extensions only apply in the event that no other specific coverage for
the indicated loss exposure is provided under this policy. If such specific coverage applies,the terms, conditions and
limits of that coverage are the sole and exclusive coverage applicable under this policy, unless otherwise noted on
this endorsement. The following is a summary of the Limits of Insurance and additional coverages provided by this
endorsement. For complete details on specific coverages, consult the policy contract wording.
Coverage Applicable Limit of Insurance Page#
Extended Property Damage Included 2
..... .....
Limited Rental Lease Agreement Contractual Liability $50,000 limit 2
Non-Owned Watercraft Less than 58 feet 2
Damage to Property You Own, Rent, or Occupy I $30,000 limit 2 u
Damage to Premises Rented to You I $1,000,000 3
HIPAA Clarification 4
Medical Payments $20,000 5
Medical... ments
P.a.y . . ..._... ... .....o.rtin9.......Period ..... ......
........... ........................ ..................................................................................3.....Y.ears5............................................m............................. ....................................
Y ExtendedReP � 9
Athletic Activities Amended 5
Supplementary Payments—Bail Bonds $5,000 5
Supplementary Payment—Loss of Earnings $1,000 per day 5
Employee Indemnification Defense Coverage $25,000 5
Key and Lock Replacement—Janitorial Services Client Coverage $10,000 limit 6
......-............................-........................................................._�-._ ._
Additional Insured—Newly Acquired Time Period Amended 6
Additional Insured—Medical Directors and Administrators Included 7
Additional Insured—Managers and Supervisors(with Fellow Included 7
Employee Coverage)
Additional Insured—Broadened Named Insured Included 7
Additional Insured—Funding Source Included 7
Additional I 11 n 11 s 11 u 11 r 11 e 11 d—Home Care Providers Included 7
Additional Insured—Managers, Landlords, or Lessors of Premises Included 7
..................................................................................................................................................................................................................._...................................................................................................................._............._
i.
Additional Insured—Lessor of Leased Equipment Included 7
Additional Insured—Grantor of Permits Included 8
Additional Insured—Vendor Included 8
Additional Insured—Franchisor Included 9
Aa&tiona.i....In.s.u.rea..._...When Required by Contract...._............_ Included ...........................9...............................
—_ _ ........._.............
Additional Insured—Owners, Lessees, or Contractors Included 9
Additional Insured—State or Political Subdivisions Included 10
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©2011 Philadelphia Indemnity Insurance Company
PI-GLD-HS (10/11)
Duties in the Event of Occurrence, Claim or Suit Included 10
.....................................m.................. ................................................... __....wwww. ..
Unintentional Failure to Disclose Hazards Included 10
_Transfer of Rights of Recovery Against Others To Us Clarification 10
Liberalization Included 11
Bodily Injury—includes Mental Anguish Included 11
Persona..L...and
....Advertisin........In...u.........._...ncli . ................................................................................ .......................
Advertising Injury includes Abuse of Process, Included 11
Discrimination
A. Extended Property Damage
SECTION I—COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE
LIABILITY, Subsection 2. Exclusions, Paragraph a. is deleted in its entirety and replaced by the
following:
a. Expected or Intended Injury
"Bodily injury"or property damage"expected or intended from the standpoint of the insured.
This exclusion does not apply to"bodily injury"or"property damage" resulting from the use of
reasonable force to protect persons or property.
B. Limited Rental Lease Agreement Contractual Liability
SECTION I—COVERAGES, COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE
LIABILITY, Subsection 2. Exclusions, Paragraph b. Contractual Liability is amended to include the
following:
(3) Based on the named insured's request at the time of claim, we agree to indemnify the
named insured for their liability assumed in a contract or agreement regarding the rental
or lease of a premises on behalf of their client, up to$50,000. This coverage extension
only applies to rental lease agreements. This coverage is excess over any renter's
liability insurance of the client.
C. Non-Owned Watercraft
SECTION I—COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE
LIABILITY, Subsection 2. Exclusions, Paragraph g. (2) is deleted in its entirety and replaced by the
following:
(2) A watercraft you do not own that is:
(a) Less than 58 feet long; and
(b) Not being used to carry persons or property for a charge;
This provision applies to any person, who with your consent, either uses or is responsible for
the use of a watercraft. This insurance is excess over any other valid and collectible
insurance available to the insured whether primary, excess or contingent.
D. Damage to Property You Own, Rent or Occupy
SECTION I —COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE
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©2011 Philadelphia Indemnity Insurance Company
PI-GLD-HS (10/11)
LIABILITY, Subsection 2. Exclusions, Paragraph j. Damage to Property, Item (1) is deleted in its
entirety and replaced with the following:
(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, unless the damage to property is caused by
your client, up to a $30,000 limit. A client is defined as a person under your direct care
and supervision.
E. Damage to Premises Rented to You
1. If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part,
the word "fire" is changed to"fire, lightning, explosion, smoke, or leakage from automatic fire
protective systems"where it appears in:
a. The last paragraph of SECTION I—COVERAGES, COVERAGE A BODILY INJURY AND
PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions; is deleted in its entirety and
replaced by the following:
Exclusions c.through n. do not apply to damage by fire, lightning, explosion, smoke, or
leakage from automatic fire protective systems to premises while rented to you or
temporarily occupied by you with permission of the owner.A separate limit of insurance
applies to this coverage as described in SECTION III—LIMITS OF INSURANCE.
b. SECTION III—LIMITS OF INSURANCE, Paragraph 6. is deleted in its entirety and replaced
by the following:
Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit is the
most we will pay under Coverage A for damages because of"property damage"to any
one premises, while rented to you, or in the case of damage by fire, lightning, explosion,
smoke, or leakage from automatic fire protective systems while rented to you or
temporarily occupied by you with permission of the owner.
c. SECTION V— DEFINITIONS, Paragraph 9.a., is deleted in its entirety and replaced by the
following:
A contract for a lease of premises. However, that portion of the contract for a lease of
premises that indemnifies any person or organization for damage by fire, lightning,
explosion, smoke, or leakage from automatic fire protective systems to premises while
rented to you or temporarily occupied by you with permission of the owner is not an
"insured contract";
2. SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, Subsection 4.Other
Insurance, Paragraph b. Excess Insurance, (1) (a) (ii) is deleted in its entirety and replaced by
the following:
That is insurance for fire, lightning, explosion, smoke, or leakage from automatic fire
protective systems for premises rented to you or temporarily occupied by you with permission
of the owner;
3. The Damage To Premises Rented To You Limit section of the Declarations is amended to the
greater of:
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©2011 Philadelphia Indemnity Insurance Company
PI-GLD-HS (10/11)
a. $1,000,000; or
b. The amount shown in the Declarations as the Damage to Premises Rented to You Limit.
This is the most we will pay for all damage proximately caused by the same event, whether such
damage results from fire, lightning, explosion, smoke, or leaks from automatic fire protective
systems or any combination thereof.
F. HIPAA
SECTION I—COVERAGES, COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY,
is amended as follows:
1. Paragraph 1. Insuring Agreement is amended to include the following:
We will pay those sums that the insured becomes legally obligated to pay as damages because
of a"violation(s)"of the Health Insurance Portability and Accountability Act(HIPAA). We have
the right and the duty to defend the insured against any"suit,""investigation,"or"civil proceeding"
seeking these damages. However, we will have no duty to defend the insured against any"suit"
seeking damages, "investigation,"or"civil proceeding"to which this insurance does not apply.
2. Paragraph 2. Exclusions is amended to include the following additional exclusions:
This insurance does not apply to:
a. Intentional,Willful, or Deliberate Violations
Any willful, intentional, or deliberate"violation(s)" by any insured.
b. Criminal Acts
Any"violation"which results in any criminal penalties under the HIPAA.
c. Other Remedies
Any remedy other than monetary damages for penalties assessed.
d. Compliance Reviews or Audits
Any compliance reviews by the Department of Health and Human Services.
3. SECTION V—DEFINITIONS is amended to include the following additional definitions:
a. "Civil proceeding" means an action by the Department of Health and Human Services (HHS)
arising out of"violations."
b. "Investigation" means an examination of an actual or alleged "violation(s)" by HHS. However,
"investigation"does not include a Compliance Review.
c. "Violation" means the actual or alleged failure to comply with the regulations included in the
HIPAA.
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PI-GLD-HS (10/11)
G. Medical Payments— Limit Increased to $20,000, Extended Reporting Period
If COVERAGE C MEDICAL PAYMENTS is not otherwise excluded from this Coverage Part:
1. The Medical Expense Limit is changed subject to all of the terms of SECTION III -LIMITS OF
INSURANCE to the greater of:
a. $20,000; or
b. The Medical Expense Limit shown in the Declarations of this Coverage Part.
2. SECTION I—COVERAGE, COVERAGE C MEDICAL PAYMENTS, Subsection 1. Insuring
Agreement, a. (3) (b) is deleted in its entirety and replaced by the following:
(b) The expenses are incurred and reported to us within three years of the date of the
accident.
H. Athletic Activities
SECTION I —COVERAGES, COVERAGE C MEDICAL PAYMENTS, Subsection 2. Exclusions,
Paragraph e.Athletic Activities is deleted in its entirety and replaced with the following:
e. Athletic Activities
To a person injured while taking part in athletics.
1. Supplementary Payments
SECTION I —COVERAGES, SUPPLEMENTARY PAYMENTS -COVERAGE A AND B are
amended as follows:
1. b. is deleted in its entirety and replaced by the following:
1. b. Up to $5000 for cost of bail bonds required because of accidents or traffic law violations
arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We
do not have to furnish these.
1.d. is deleted in its entirety and replaced by the following:
1. d. All reasonable expenses incurred by the insured at our request to assist us in the
investigation or defense of the claim or"suit', including actual loss of earnings up to $1,000 a
day because of time off from work.
J. Employee Indemnification Defense Coverage
SECTION I—COVERAGES, SUPPLEMENTARY PAYMENTS—COVERAGES A AND B the
following is added:
We will pay, on your behalf, defense costs incurred by an "employee"in a criminal proceeding
occurring in the course of employment.
The most we will pay for any"employee"who is alleged to be directly involved in a criminal
proceeding is $25,000 regardless of the numbers of"employees,"claims or"suits" brought or
persons or organizations making claims or bringing "suits.
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0 2011 Philadelphia Indemnity Insurance Company
PI-GLD-HS (10/11)
K. Key and Lock Replacement—Janitorial Services Client Coverage
SECTION I —COVERAGES, SUPPLEMENTARY PAYMENTS—COVERAGES A AND B is
amended to include the following:
We will pay for the cost to replace keys and locks at the"clients" premises due to theft or other
loss to keys entrusted to you by your"client," up to a $10,000 limit per occurrence and $10,000
policy aggregate.
We will not pay for loss or damage resulting from theft or any other dishonest or criminal act that
you or any of your partners, members, officers, "employees", "managers", directors,trustees,
authorized representatives or any one to whom you entrust the keys of a"client'for any
purpose commit, whether acting alone or in collusion with other persons.
The following, when used on this coverage, are defined as follows:
a. "Client' means an individual, company or organization with whom you have a written contract
or work order for your services for a described premises and have billed for your services.
b. "Employee" means:
(1) Any natural person:
(a) While in your service or for 30 days after termination of service;
(b) Who you compensate directly by salary, wages or commissions; and
(c) Who you have the right to direct and control while performing services for you; or
(2) Any natural person who is furnished temporarily to you:
(a) To substitute for a permanent"employee"as defined in Paragraph (1)above, who is
on leave; or
(b) To meet seasonal or short-term workload conditions;
while that person is subject to your direction and control and performing services for you,
(3) "Employee"does not mean:
(a) Any agent, broker, person leased to you by a labor leasing firm, factor, commission
merchant, consignee, independent contractor or representative of the same general
character; or
(b) Any"manager,"director or trustee except while performing acts coming within the
scope of the usual duties of an "employee."
c. "Manager" means a person serving in a directorial capacity for a limited liability company.
L. Additional Insureds
SECTION II—WHO IS AN INSURED is amended as follows:
1. If coverage for newly acquired or formed organizations is not otherwise excluded from this
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©2011 Philadelphia Indemnity Insurance Company
PI-GLD-HS (10/11)
Coverage Part, Paragraph 3.a. is deleted in its entirely and replaced by the following:
a. Coverage under this provision is afforded until the end of the policy period.
2. Each of the following is also an insured:
a. Medical Directors and Administrators—Your medical directors and administrators, but
only while acting within the scope of and during the course of their duties as such. Such
duties do not include the furnishing or failure to furnish professional services of any physician
or psychiatrist in the treatment of a patient.
b. Managers and Supervisors—Your managers and supervisors are also insureds, but
only with respect to their duties as your managers and supervisors. Managers and
supervisors who are your"employees"are also insureds for"bodily injury"to a co-
"employee"while in the course of his or her employment by you or performing duties
related to the conduct of your business.
This provision does not change Item 2.a.(1)(a) as it applies to managers of a limited
liability company.
c. Broadened Named Insured—Any organization and subsidiary thereof which you control and
actively manage on the effective date of this Coverage Part. However, coverage does not
apply to any organization or subsidiary not named in the Declarations as Named Insured, if
they are also insured under another similar policy, but for its termination or the exhaustion of
its limits of insurance.
d. Funding Source—Any person or organization 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 that person or organization.
e. Home Care Providers—At the first Named Insured's option, any person or organization
under your direct supervision and control while providing for you private home respite or
foster home care for the developmentally disabled.
f. Managers, Landlords, or Lessors of Premises—Any person or organization with respect
to their liability arising out of the ownership, maintenance or use of that part of the premises
leased or rented to you 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 that person or organization.
g. Lessor of Leased Equipment—Automatic Status When Required in Lease Agreement
With You—Any person or organization from whom you lease equipment when you and such
person or organization have agreed in writing in a contract or agreement that such person or
organization is to be added as an additional insured on your policy. Such person or
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PI-GLD-HS (10/11)
organization is an insured only with respect to liability for"bodily injury," "property damage"or
"personal and advertising injury" caused, in whole or in part, by your maintenance, operation
or use of equipment leased to you by such person or organization.
A person's or organization's status as an additional insured under this endorsement ends
when their contract or agreement with you for such leased equipment ends.
With respect to the insurance afforded to these additional insureds, this insurance does not
apply to any"occurrence"which takes place after the equipment lease expires.
h. Grantors of Permits—Any state or political subdivision granting you a permit in connection
with your premises subject to the following additional provision:
(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 the 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, hoist away openings, sidewalk vaults, street banners or decorations and
similar exposures;
(b) The construction, erection, or removal of elevators; or
(c) The ownership, maintenance, or use of any elevators covered by this insurance.
i. Vendors—Only with respect to"bodily injury" or"property damage"arising out of"your
products" which are distributed or sold in the regular course of the vendor's business, subject
to the following additional exclusions:
(1) The insurance afforded the vendor does not apply to:
(a) "Bodily injury" or"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 by you;
(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 substitution of parts under instructions from the
manufacturer, and then repackaged in the original container;
(e) Any failure to make such inspections, adjustments, tests or servicing as the vendor
has agreed to make or normally undertakes to make in the usual course of business,
in connection with the distribution or sale of the products;
(f) Demonstration, installation, servicing or repair operations, except such operations
performed at the vendor's premises in connection with the sale of the product;
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PI-GLD-HS (10/11)
(g) Products which, after distribution or sale by you, have been labeled or relabeled or
used as a container, part or ingredient of any other thing or substance by or for the
vendor; or
(h) "Bodily injury" or"property damage"arising out of the sole negligence of the vendor
for its own acts or omissions or those of its employees or anyone else acting on its
behalf. However, this exclusion does not apply to:
(i) The exceptions contained in Sub-paragraphs (d) or(f); or
(ii) Such inspections, adjustments, tests or servicing as the vendor has agreed to
make or normally undertakes to make in the usual course of business, in
connection with the distribution or sale of the products.
(2) This insurance does not apply to any insured person or organization, from whom you
have acquired such products, or any ingredient, part or container, entering into,
accompanying or containing.
j. Franchisor—Any person or organization with respect to their liability as the grantor of a
franchise to you.
k. As Required by Contract—Any person or organization where required by a written contract
executed prior to the occurrence of a loss. Such person or organization is an additional
insured for"bodily injury,""property damage" or"personal and advertising injury" but only for
liability arising out of the negligence of the named insured. The limits of insurance applicable
to these additional insureds are the lesser of the policy limits or those limits specified in a
contract or agreement. These limits are included within and not in addition to the limits of
insurance shown in the Declarations
II. Owners, Lessees or Contractors—Any person or organization, but only with respect to
liability for"bodily injury,""property damage"or"personal and advertising injury"caused, in
whole or in part, by:
(1) Your acts or omissions; or
(2) The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured when required by a
contract.
With respect to the insurance afforded to these additional insureds, the following additional
exclusions apply:
This insurance does not apply to"bodily injury"or"property damage"occurring after:
(a) All work, including materials, parts or equipment furnished in connection with such
work, on the project(other than service, maintenance or repairs)to be performed by
or on behalf of the additional insured(s) at the location of the covered operations has
been completed; or
(b) That portion of"your work"out of which the injury or damage arises has been put to
its intended use by any person or organization other than another contractor or
subcontractor engaged in performing operations for a principal as a part of the same
project.
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PI-GLD-HS (10/11)
m. State or Political Subdivisions—Any state or political subdivision as required, subject to
the following provisions:
(1) 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, and is required by
contract.
(2) This insurance does not apply to:
(a) 'Bodily injury,""property damage" or"personal and advertising injury" arising out of
operations performed for the state or municipality; or
(b) 'Bodily injury"or"property damage" included within the"products-completed
operations hazard."
M. Duties in the Event of Occurrence,Claim or Suit
SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, Paragraph 2. is amended as
follows:
a. is amended to include:
This condition applies only when the'occurrence"or offense is known to:
(1) You, if you are an individual;
(2) A partner, if you are a partnership; or
(3) An executive officer or insurance manager, if you are a corporation.
b. is amended to include:
This condition will not be considered breached unless the breach occurs after such claim or"suit"
is known to:
(1) You, if you are an individual;
(2) A partner, if you are a partnership; or
(3) An executive officer or insurance manager, if you are a corporation.
N. Unintentional Failure To Disclose Hazards
SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, 6. Representations is
amended to include the following:
It is agreed that, based on our reliance on your representations as to existing hazards, if you
should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of
this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure.
O. Transfer of Rights of Recovery Against Others To Us
SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, 8. Transfer of Rights of
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©2011 Philadelphia Indemnity Insurance Company
PI-GLD-HS (10/11)
Recovery Against Others To Us is deleted in its entirety and replaced by the following:
If the insured has rights to recover all or part of any payment we have made under this Coverage
Part, those rights are transferred to us. The insured must do nothing after loss to impair them. At
our request, the insured will bring "suit"or transfer those rights to us and help us enforce them.
Therefore, the insured can waive the insurer's rights of recovery prior to the occurrence of a
loss, provided the waiver is made in a written contract.
P. Liberalization
SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, is amended to include the
following:
If we revise this endorsement to provide more coverage without additional premium charge, we
will automatically provide the additional coverage to all endorsement holders as of the day the
revision is effective in your state.
Q. Bodily Injury—Mental Anguish
SECTION V— DEFINITIONS, Paragraph 3. Is deleted in its entirety and replaced by the following:
"Bodily injury" means:
a. Bodily injury, sickness or disease sustained by a person, and includes mental anguish
resulting from any of these; and
b. Except for mental anguish, includes death resulting from the foregoing (item a. above) at any
time.
R. Personal and Advertising Injury—Abuse of Process, Discrimination
If COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY COVERAGE is not
otherwise excluded from this Coverage Part, the definition of"personal and advertising injury" is
amended as follows:
1. SECTION V—DEFINITIONS, Paragraph 14.b. is deleted in its entirety and replaced by the
following:
b. Malicious prosecution or abuse of process;
2. SECTION V—DEFINITIONS, Paragraph 14. is amended by adding the following:
Discrimination based on race, color, religion, sex, age or national origin, except when:
a. Done intentionally by or at the direction of, or with the knowledge or consent of:
(1) Any insured; or
(2) Any executive officer, director, stockholder, partner or member of the insured;
b. Directly or indirectly related to the employment, former or prospective employment,
termination of employment, or application for employment of any person or persons by an
insured;
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0 2011 Philadelphia Indemnity Insurance Company
PI-GLD-HS (10/11)
c. Directly or indirectly related to the sale, rental, lease or sublease or prospective sales, rental,
lease or sub-lease of any room, dwelling or premises by or at the direction of any insured; or
d. Insurance for such discrimination is prohibited by or held in violation of law, public policy,
legislation, court decision or administrative ruling.
The above does not apply to fines or penalties imposed because of discrimination.
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0 2011 Philadelphia Indemnity Insurance Company
AMERI-9 OP ID: EW
,4�o�zo CERTIFICATE OF LIABILITY INSURANCE I DATE 07/11/17
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(les) 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
360-254-2420 NAME:
Waller Insurance Inc.
5512 NE 109th Ct.Suite G 360-254-0806 PHONE No, Ext); FAX No):
Vancouver,WA 98662 E-MAPL
Eva Waller ADDRESS.
INSURER(S)AFFORDING COVERAGE NAIC q
INSURERA:Hartford Insurance Company
INSURED AMERICAN CHESS INSTITUTE INSURERBa
Code to the Future
13415 SE Silver Circle INSURER C.
Vancouver,WA 98683 INSURER D
INSURER E:
„ INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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,
ILTR TYPE OF INSURANCE ' 'DOL' Uak POLICY EFF POLICY EXP LIMITS
„(,�,SR WVO POLICY NUMBER IMMIDDIYYYVI (MMIDDIYVYY)
GENERAL LIABILITY
EACH OCCURRENCE $
DAMAGE:`70 RENTED
COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) S
CLAIMS-MADE 1 OCCUR MED EXP(Any one person) S
PERSONAL&ADV INJURY S
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP APG $
POLICY (PE O, LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMI7
(Ea accident),,,,,, S
ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY
HIRED AUTOS AUTOS (Per accident)DAMAGE $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE f AGGREGATE $
DED RETENTION$ S
WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ❑ E L ITQRY I„IMIT5 I I FR
TATO- OTH-i
A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN X 52WBCZU4308 07/01/17 07/01/18 HACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? NIA
(Mandatorym NH) EL DISEASE-EA EMPLOYEE:. $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S 1,000,000
DESCRIPTION OF OPERATIONS I'LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Waiver of Subrogation for City of EI Segundo Recreation
CERTIFICATE HOLDER CANCELLATION
ELSEGUN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CI of EI Segundo Recreation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City g ACCORDANCE WITH THE POLICY PROVISIONS.
300 East Pine Ave
EL Segundo,CA 90245
AUTHORIZED REPRESENTATIVE
Eva Waller
©1988-2010 ACORD CORPORATION. All rights reserved„
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
tr ',
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF OUR RIGHT TO RECOVER FROM
OTHERS ENDORSEMENT - CALIFORNIA
Policy Number: 52 WBC ZU4308 Endorsement Number: 02
Effective Date: 07/11/17 Effective hour is the same as stated on the Information Page of the policy.
Named Insured and Address: AMERICAN CHESS INSTITUTE INC CODE
TO THE FUTURE
13415 SE SILVER CIR
VANCOUVER, WA 98683
We have the right to recover our payments from 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 contract that requires you to obtain this agreement from 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 Job Description
MORENO VALLEY UNIFIED SCHOOL EDUCATIONAL CONSULTING
DISTRICT ITS BOARD, OFFICERS,
AGENTS, EMPLOYEES, AND
VOLUNTEERS PURCHASING DEPT `„
25634 ALESSANDRO BLVD
MORENO VALLEY CA 92553
CITY OF EL SEGUNDO RECREATION COMPUTER CAMP
300 EAST PINE AVENUE
EL SEGUNDO, CA 90245
Countersigned by
Authorized Representative
Form WC 04 03 06 (1) Printed in U.S.A,
Process Date: 07/17/17 Policy Expiration Date: 07/01/18