HomeMy WebLinkAboutAgreements/Contracts - BOCCJerry T. Gingrich
From: Denver Morford <morford.denver@gmail.com>
Sent: Wednesday, August 25, 2021 9:42 AM
To: Commissioners
Subject: 9/11 Site Use Request
Attachments: site map.pdf
Thank you for the call this morning. Weare requesting to use the front court house lawn on 9/11 to host a banquet
honoring Hall of Fame inductees from Ephrata High School. We plan to have the event catered and will set up the
campus with multiple lights to show off how gorgeous of a venue the courthouse is.
Tiger Boosters is hosting the event and is a registered 501c3 charity.
Please let me know if there is anything else I need to provide to secure the premises. Thank you!
Denver Morford
DSEM LLC
TwoGoofyDogs.com
EphrataHouse.com
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MARKEL Evanston Insurance Company
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COMMON POLICY DECLARATIONS
Promotion, Event and Prize Purchasing Group
MASTER POLICY NUMBER: 3DS5472
CERTIFICATE NUMBER: 2234879
Named Insured and Mailing Address:
Tiger Boosters
Denver Morford
159 Basin St SW #133, Ephrata, WA 98823
Policy Period: From 09/11/21 to 09/12/21 at 12:01 A.M. Standard Time at your mailing address (shown above).
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL
THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE
INSURANCE AS STATED IN THIS POLICY.
COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS
I LIMITS OF INSURANCE I
General Aggregate Limit (other than Products/Completed Operations) $2,000,000
Products/Completed Operations Aggregate Limit $17000,000
Personal and Advertising Injury Limit $1,000,000
Each Occurrence Limit $1,000,000
Damage to Premises Rented to You Limit $100,000 Any One Premises
Medical Expense Limit $5,000 Any One Person
These declarations, together with the Common Policy Conditions and Coverage Form(s) and any
Endorsement(s), complete the above numbered policy.
I FORMS AND ENDORSEMENTS
SEE FORMS SCHEDULE - MDIL 1001
ADDITIONAL INSURED — DESIGNATED PERSON OR ORGANIZATION - MEGL 2217 01 19
Producer Number, Name and Mailing Address
East Main Street Insurance Services, Inc.
Will Maddux
PO Box 1298
Grass Valley, CA 95945
Countersigned:
MDIL 1000 08 11
08/25/2021
Date
Premium: $87.00
Surplus Tax: $1.74
Stamp Fee: $0.09
Other Fee: $0.00
By:
AUTHORIZED REPRESENTATIVE
Page 1 of 1
00
ACCORD'' CERTIFICATE OF LIABILITY INSURANCE DA78/26/2 21
.... ...........
C8/2G12921
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 poli+cy(ies) must have ADDITIONAL INSURED provision' ®r be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the poll , oert In poticies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of ,such eiAors ment(s).
PRODUCEp C ACT Cheryl Kano
Cheryl Insurance Agency I IIA LLC PHONE _ - ��
AIC No Ext o
: (509) 754 2550 N).
Cheryl Kono E-MAIL "µ
ry ADDRESS: ckono@farmersagent.com
858 Basin St SW Ste A
_ INSURER AFFORDING COVERA+GE, NAIL #
Ephrata WA 98823 INSURER A : Evanston Insurance Company
us._,r._............ __"_.."". _"^.... .,, w _ �. .,_
` 35378
INSURE[;
INSURER B • J
Tiger Boasters INSURER C
Denver Morford
INSURER D
159 Basin St SW #133 INSURER E :
Ephrata WA 98823 INSURER F:
COVERAGES CERTIFICATE NUMBER _REVISI.ON NUMBER: WNW
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.
IMSiI . oDL sly = POLICY EFF POLICY ETP
LTR I TYPE OF INSURANCE �
POLICY NUMBER:MMTDVY Y ' MWDD/YYYY I LIMITS
COMMERCIAL GENERAL LIABILITY , .. �
t EACH OCCURRENCE $ 1,000,000
CLAIMS -MADE OCCUR E� NTED '� UQD
y . .r PREMISES (Ea occurrence) OBD,
` Hast Liquor Liability � - _ ..H_.�� ,..�.�.�.._.
_."..___."........_,........"............. "..,_.,nom 1ne person)
:MED EXP o 5,0(}(j
A _ Retail Liquor Liability Y 3DS5472-M2234879 09/11/2021 09/1212921 =PERSONAL&ADV INJURY 1,940,000
GEN'L AGGREGATE LIMIT APPLIES PER: 12:01 AM I 12:01 AM GENERAL AGGREGATE 2,000,000
.j
POLICY F7 PRO-
JECT LfJG j PRODUCTS - COMP/CSP AGG ' $ 1,000,�
_.
_.
!! E
Deductible
$
10000
------------
_,
3 AItITOMOBILE LIABILITY
.-_COMBINED SINGLE -LIMIT 1
`
, IEe accident
ANY AUTO _ . _ n......
Per person)LY INJURY ( $
Bt?DI
OWNED SCHEDULED
AUTOS ONLY � Q AUTOS � � I � BODILY INJURY (Per accident) t $
HIRED N��N-CJWNED � � f'RaF'EF�T1( bAN1AfiE
.� AUTOS ONLY -
w ;AUTOS ONLY accident•
S
° UMBRELLA LIAR I
OCCUR EACH
m .. ' ._...."...._i•
OCCURRENCE
EXCESS
EXCESS LAR CLAIMS -MARE �,.,
( AGGREGATE
I DED RETENTION $ '
1
WORKERS COMPENSATION _ � � _ PER � QTH
AND EMPLOYERS' LIABILITY Y! N € I ]STATUTE ER��
{a...
ANYPROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT
OFFICER/MEMBEREXCLUDED? N I A
(Mandatory In MH) s
E.L. DISEASE - EA EMPLOYEE $
'If yes, describe under ! :...
f DESCRIPTION OF OPERATIONS below
' I _ E.L. DISEASE - POLICY LIMIT $ ,
I
------------
s
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101 Additional Remarks Schedule, may be attached If more space Is required)
Certificate holder listed below is named as additional insured per attached MEGL 2217 01 19.
Attendance: 150, Event Type: Banquet.
CERTIFICATE HOLDER _. CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Grant County
35 C St NW
Ephrata
WA 98823
AUTHORIZED REPRESENTATIVE
Cheryl Dano
01988-2015 C�
ACORD 25 (2016M3) The ACORD name and logo are registered marks of ACORD
RD COR. RATION. All rights reserved.
COMMERCIAL GENERAL LIABILITY
oil POLICY NUMBER: 3DS5472-M2234879
hLWEr
EVA(VSTC}N INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
NAMM
Name Of Additional Insured Person(s) Or Organization(s):
Grant County
35 C St NW
Ephrata, WA 98823
A. Section If — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown
in the Schedule of this endorsement, but only with respect to liability for "bodily injury", "property damage" or "personal
and advertising injury" caused, in whole or in part, by the acts or omissions of any insured listed under Paragraph 1. or
2. of Section If — Who Is An Insured:
I., In the performance of your ongoing operations; or
2. In connection with your premises owned by or rented to you.
However:
1. The insurance afforded to such additional insured only applies to the extent permitted by law; and
2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such
additional insured will not be broader than that which you are required by the contract or agreement to provide for
such additional insured.
B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of
Insurance:
If coverage provided to the additional insured is required by a contract or agreement,, the most we will pay on behalf of
the additional insured is the amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
All other terms and conditions remain unchanged.
MEGL 2217 01 19 Includes copyrighted material of Insurance Services Office, Inc,, Page I of I
with its permission.