Cert of Ins 06282016.pdfPOLICY NUMBER: 0100118-02-902779
ADDRESS TYPE: ADDITIONAL INSURED
CITY OF EDMONDS
BUILDING DIVISION
121 5TH AVE N
EDMONDS WA 98020-3145
03-190
YOUR REPRESENTATIVE:
DAWN DURHAM
ROCKY MOUNTAIN WEST DIVISION
CHURCH MUTUAL INS CO
3000 SCHUSTER LANE
MERRILL WI 54452
(800) 554-2642
EFFECTIVE: 06/28/16
RECEIVED
JUN 2 12016
DEVELOPMENT SERVICES
2016
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IUVR ANCE COMPANY
CHURCH MUTUAL INSURANCE COMPANY
3000 Schuster Lane, P.O. Box 357, Merrill, WI 54452
COMMON POLICY DECLARATIONS PAGE
POLICY NO.: 0100118-02-902779
ITEM 1. NAMED INSURED AND ADDRESS:
COMMUNITY CHRISTIAN FELLOWSHIP
615 GLEN ST
EDMONDS WA 98020-3028
ITEM 2. POLICY PERIOD: FROM 06/28/16 TO 06/28/19
12:01 A.M. STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE
ITEM 3. THE NAMED INSURED IS: RELIGIOUS INSTITUTION
ITEM 4. AGENT: 03-190
DAWN DURHAM
ROCKY MOUNTAIN WEST DIVISION
CHURCH MUTUAL INS CO
3000 SCHUSTER LANE
MERRILL WI 54452
(800) 554-2642
ITEM 5. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS:
FORMS AND ENDORSEMENTS WHICH APPLY TO THIS ENTIRE POLICY:
A 050(01-98)
MUTUAL AND COMMON POLICY CONDITIONS
A 051(06-87)
CALCULATION OF PREMIUM
A 9009 WA(01-15)
WASHINGTON CONDITIONAL EXCLUSION OF TERRORISM
A 937(12-11)
WASHINGTON CHANGES
UN 720(01-15)
NOTICE - DISCLOSURE OF TERRORISM PREMIUM
Mutual Company
Nonassessable
0100118-02-813164
(RENEWAL OF)
PROPERTY COVERAGE PART AND ITS FORMS AND ENDORSEMENTS:
A 100(01-01)
PROPERTY CONDITIONS
A 1001(01-08)
IDENTITY RECOVERY COVERAGE FORM
A 1009.1 WA(07-09)
WATER EXCLUSION ENDORSEMENT
A 101(04-06)
BUILDING AND PERSONAL PROPERTY COVERAGE - RELIGIOUS
A 101.1 WA(02-05) OPTIONAL COVERAGES - AUTOMATIC INCREASE IN INSURANCE
A 127(04-06)
CAUSES OF LOSS - SPECIAL FORM
A 154(10-99)
SYSTEMS/EQUIPMENT BREAKDOWN COVERAGE FORM
A 177(04-06)
WASHINGTON CHANGES
A 177.1(04-06)
WASHINGTON CHANGES - EXCLUDED CAUSES OF LOSS
A 945.2(01-15)
CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM
GENERAL LIABILITY COVERAGE PART AND ITS FORMS AND ENDORSEMENTS:
A 052(06-87) NUCLEAR ENERGY LIABILITY EXCLUSION - BROAD FORM
A 200(01-04) GENERAL LIABILITY COVERAGE PART - OCCURRENCE BASIS
A 200.1(12-06) AMENDATORY ENDORSEMENT - PERSONAL INJURY
_C
Mutual
INSURANCE COMPANY
A 001 CD(10-99) - WA PAGE 1 ISSUED DATE: 06/10/16
POLICY NO.: 0100118-02-902779
GENERAL LIABILITY COVERAGE PART AND ITS FORMS AND ENDORSEMENTS:
A 200.2(12-07)
BODILY INJURY DEFINITION
A 2012(12-07)
CORPORATE ENTITY ENDORSEMENT
A 2013(12-07)
MEDICAL EXPENSE AMENDMENT
A 202(01-04)
GENERAL LIABILITY ADDITIONAL PROVISIONS - RELIGIOUS
A 221(01-98)
MANAGERS OR LESSORS OF PREMISES
A 224(01-04)
STATE OR POLITICAL SUBDIVISIONS - PERMITS
A 249 WA(08-04)
STOP GAP - EMPLOYERS LIABILITY COVERAGE ENDORSEMENT
A 251(09-94)
EXCLUSION - LEAD LIABILITY
A 253(12-07)
LEGAL DEFENSE COVERAGE FORM
A 254(05-08)
AMEND OF INSURING AGREEMENT - KNOWN INJURY OR DAMAGE
A 255(01-04)
CATASTROPHIC VIOLENCE RESPONSE COVERAGE
A 262(01-04)
SEXUAL MISCONDUCT OR SEXUAL MOLESTATION LIAB AND MED
A 268(05-03)
WAR LIABILITY EXCLUSION
A 9006(01-15)
EXCL OF PUN DAMAGES RELATED TO A CERT ACT OF TERROR
A 937.1(04-06)
WASHINGTON CHANGES
A 937.2(07-13)
WASHINGTON CHANGES - DEFENSE COSTS
A 945.3(01-15)
CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM
CRIME COVERAGE PART AND ITS FORMS AND ENDORSEMENTS:
A 300(06-87)
CRIME CONDITIONS FORM
A 302(05-89)
CHURCH THEFT OF MONEY AND SECURITIES COVERAGE FORM
A 358(06-03)
WASHINGTON CHANGES
PROFESSIONAL LIABILITY
COVERAGE PART AND ITS FORMS AND ENDORSEMENTS:
A 500(01-04)
COUNSELING PROFESSIONAL LIABILITY COVERAGE -OCCURRENCE
A 501.7(06-15)
EXCLUSION - FINANCIAL COUNSELING
A 505(12-04)
DIRECTORS, OFFICERS & TRUSTEES LIAB - CLAIMS MADE
A 505.1(12-07)
SPOUSAL LIABILITY
A 520(01-04)
EMPLOYMENT PRACTICES LIABILITY COVERAGE
A 529(12-04)
EMPLOYMENT PRACTICES LIABILITY COVERAGE AMENDMENT
A 530(12-06)
AFFILIATED ENTITY DISPUTE LEGAL DEFENSE COVERAGE
A 534(12-07)
CORPORATE ENTITY ENDORSEMENT
A 535(12-07)
CORPORATE ENTITY ENDORSEMENT DO&T LIABILITY
A 9006(01-15)
EXCL OF PUN DAMAGES RELATED TO A CERT ACT OF TERROR
A 937.1(04-06)
WASHINGTON CHANGES
A 937.2(07-13)
WASHINGTON CHANGES - DEFENSE COSTS
A 945.3(01-15)
CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM
DOT 913-WA(02-07)kPPLICATION
FOR DIRECTORS, OFFICERS & TRUSTEES LIAB
EPL 914-WA(02-07)APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY
HIRED AND NONOWNED AUTOMOBILE LIABILITY COVERAGE PART AND ITS FORMS AND
ENDORSEMENTS:
A 600(01-04)
HIRED AND NONOWNED AUTO LIAB - RELIGIOUS INSTITUTION
A 602(06-00)
MEDICAL EXPENSE COVERAGE
A 602.1(12-07)
MEDICAL EXPENSE AMENDMENT
A 605 WA(12-06)
RENTAL AUTOMOBILE CONTRACTUAL LIABILITY ENDORSEMENT
A 606(12-07)
CORPORATE ENTITY ENDORSEMENT
A 692(04-93)
WASHINGTON CHANGES - RENEWAL AUTOMOBILE ENDORSEMENT
A 9006(01-15)
EXCL OF PUN DAMAGES RELATED TO A CERT ACT OF TERROR
A 937.2(07-13)
WASHINGTON CHANGES - DEFENSE COSTS
A 945.3(01-15)
CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM
A 001 CD(10-99) - WA PAGE 2
POLICYNO.: 0100118-02'902770
ITEK86. PREMIUM: |NRETURN FOR THE PAYMENT OFTHE PREMIUM, AND SUBJECT TO
ALL THE TERMS OFTHIS POLICY, VVEAGREE WITH YOU TOPROVIDE THE INSURANCE A8
STATED |NTHIS POLICY.
$8452.00 DUE ATINCEPTION. PREMIUM SUBJECT TOADJUSTMENT ATEACH ANNIVERSARY.
°° SUMMARY OFADDITIONAL CHARGES (INCLUDED |NANNUAL PREMIUM) °^
TERRORISM RISK INSURANCE: $ 75.00 ANNUAL CHARGE
This policy includes copyrighted material mChurch Mutual Insurance Company
Copyright, Church Mutual Insurance Company, 1n95
Includes copyrighted material mInsurance Services Office, Inc *in Its permission
Copyright, Insurance Services Office, Inc,, 1984 & 1994
A 001 CDf 10-99) - WA PAGE 3 ISSUED DATE
GENERAL LIABILITY COVERAGE PART
DECLARATIONS PAGE
POLICY NO.: 0100118-02-902779
ITEM 1. LIMITS OF INSURANCE:
GENERAL AGGREGATE LIMIT (OTHER THAN PRODUCTS - COMPLETED $ 3,000,000
OPERATIONS AND SEXUAL MISCONDUCT OR SEXUAL MOLESTATION)
PRODUCTS -COMPLETED OPERATIONS AGGREGATE LIMIT $ 1,000,000
EACH OCCURRENCE LIMIT (BODILY INJURY AND PROPERTY DAMAGE $ 1,000,000
COMBINED)
PERSONAL AND ADVERTISING INJURY LIMIT (COMBINED) $ 1,000,000
MEDICAL EXPENSE LIMIT - ANY ONE PERSON (OTHER THAN SEXUAL
MISCONDUCT OR SEXUAL MOLESTATION) $ 10,000
PROPERTY DAMAGE LEGAL LIABILITY - ANY ONE OCCURRENCE $ 300,000
SEXUAL MISCONDUCT OR SEXUAL MOLESTATION LIMIT (COMBINED) - ALL
LOCATIONS AND OPERATIONS
EACH CLAIM LIMIT $ 300,000
AGGREGATE LIMIT $ 300,000
SEXUAL MISCONDUCT OR SEXUAL MOLESTATION MEDICAL EXPENSE LIMIT
ANY ONE PERSON $ 10,000
AGGREGATE LIMIT $ 50,000
LEGAL DEFENSE COVERAGE LIMIT
EACH DEFENSIBLE INCIDENT LIMIT
$
5,000
AGGREGATE LIMIT
$
15,000
CATASTROPHIC VIOLENCE RESPONSE
PER PERSON LIMIT
$
50,000
EACH VIOLENT INCIDENT LIMIT
$
300,000
VIOLENT INCIDENT AGGREGATE LIMIT
$
300,000
EMPLOYERS LIABILITY (STOP GAP) COVERAGE
BODILY INJURY BY ACCIDENT --EACH ACCIDENT
$
1,000,000
BODILY INJURY BY DISEASE --EACH EMPLOYEE
$
1,000,000
BODILY INJURY BY DISEASE --AGGREGATE LIMIT
$
1,000,000
ITEM 2. DESCRIPTION AND CLASSIFICATION OF PREMISES AND OPERATIONS:
ALL PREMISES AND OPERATIONS UNLESS EXCLUDED IN ITEM 3 BELOW.
NONE
ITEM 3. EXCLUSION ENDORSEMENTS:
NONE
A 001 G(03-04) - WA
°Chi
utua
PAGE 1 ISSUED DATE: 06/10/16
POLICY NO.: 0100118-02-902779
OTHER ENDORSEMENTS.:.
ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES ENDORSEMENT,
SCHEDULE OF ADDITIONAL PERSONS OR ORGANIZATIONS INSURED:
EDMONDS CENTER FOR THE ARTS
410 4TH AVE N
EDMONDS, WA 98020-3119
PREMISES/BUILDINGS INCLUDED: 002 002
ADDITIONAL INSURED - STATE OR POLITICAL SUBDIVISIONS - PERMITS.
SCHEDULE OF STATE OR POLITICAL SUBDIVISIONS INSURED:
CITY OF EDMONDS
BUILDING DIVISION
121 5TH AVE N
EDMONDS, WA 98020-3145
ENCROACHMENT OF PUBLIC SPACE
PREMISES/BUILDINGS INCLUDED: 001 001
A 001 G(03-04) - WA PAGE 2 ISSUED DATE: 06/10/16
POLICY NO.: 0100118-02-902779
06/28/16
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - STATE OR POLITICAL SUBDIVISIONS - PERMITS
This endorsement modifies insurance provided under the General Liability Coverage Part.
The following is added to the General Liability Additional Provisions Form.
A. ADDITIONAL INSURED - STATE OR
POLITICAL SUBDIVISIONS - PERMITS
1, Paragraph C., Who Is An Insured, is amended
to include as an insured any state or political
subdivision shown in the applicable schedule
in the Declarations Page, subject to the
following provisions:
a, 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.
b. This insurance does not apply to:
(1) Injury for "bodily injury," "property
damage," "personal injury," or
"advertising injury" arising out of
operations performed for the state or
municipality; or
(2) Injury for "bodily injury" or "property
damage" included within the
"products -completed operations
hazard."
Refer to the Declarations Page to determine the
insured state or political subdivision.
A 224 (01-04) Copyright, Church Mutual insurance Company, 2004 Page 1 of 1
Includes copyrighted r rwtekil of in5uraince Ser' koc Office, Inc., with its permission,
Coganyurvgm, insuranctk,'^'"uesvin' es 011fca, Inc., 1995.
POLICY NO.: 0100118-02-902779 06/28/16