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19-047.00 CVSD: Facility Use for Pavement Preservation Project Meeting i T-047 Ai-• --.) . • Permit for Use of CENTRAL VALLEY School Facilities & Playfields {CMOOI DISTRICT I156 Organization or Team c l f� c)-/Date '/ ill j0( V \ School Cir clenry=v-kk-pwl • Person in Charge VA .- l it L'1 t Field, Diamond or Facility Address tc3-(D ae Starting Date• -- aiit) d01(1 lime s t ND ), Ending Date n. • - L- c)019 Time '7 CO pen cit e tate 'a► Zip qi ZI p Week(s)of Event Phon (f i 136 Z.3t> Day(s)of Week Email Doors Open A.M. P.M. Activity Classification Fee Insurance from Board Policy#4260 from Administrative Procedure#4260AP ❑ Class I Box No. (1-24) Use Fee per Hour $ ❑ Yes-Certificate of Insurance for all use is with district.'1 Custodian:_— hrs X$ hr= ❑ Class II Box No. (25-48) Name Yes Organization's Certificate Food Servs hrs X$ hr- of Insurance attached.**2 ❑ Class III Name ❑ Yes Individual/Parent Hold Admission Charge Other Staff hrs X$ hr= Harmless Agreement Expected Attendance Name Signed.***3 Estimate User Cost: $ *1. YMCA/Soccer Association/AAU/County Parks/et cetera **2. Scouts, 4-H, SCOPE, Percussionauts, Club sports, Grange, Church groups, et cetera *"*3. Individuals who may not be insured with an insurance company • Explanation and/or special conditions (Users provide their own sanitary facilities) V Cr r C_ mo i S 'pa�1e+� �sec�v r Cil \Ire • . 1 11 Hold Harmless Agreement The undersigned agrees and acknowledges that the use of the facilities of Central Valley School District No.356 is without representation or warranties by the school district, its employees and agents,as to the condition of the property.The undersigned agrees to take full responsibility for any and all damage to the property andlor injury to persons allowed or reasonably anticipated to be on the premises by the undersigned.The undersigned specifically waives any and all rights,remedies,or causes of action against Central Valley School District No.356,its employees and agents,from any and all claims arising out of the use of the premises and agrees to reimburse the school district for any and all judgements,costs and expenses,including attorney's fees,incurred by the school district in the defense of any such action. The undersigned further agrees and warrants that should the respective organization or group use school district facilities,and serve or prepare any food or beverage,it shall comply with all applicable federal,state and local laws and regulations regarding the serving and preparation of such food or beverage.The undersigned organization specifically agrees to contact the Spokane County Health District In order to ensure that all required regulations and requirements are met,including,but not limited to,any applicable food permit that is required to be obtained, I agree that the above Information Is correct and the building facilities will be used according to the policies and procedures of the Central Valley School District I further agree to reimburse the school district for actual user costs as described in the final billing. ,a private non-profit youth sports group,verifies all coaches,athletes and their parent/guardian have complied with mandated policies for the management of concussions and head injuries as prescribed by HB 1824,section 2. Attached is a proof of insurance under an accident and liability policy issued by an insurance company authorized to do business in Washington State covering any injury or damage with at least$1,000,000 due to bodily injury or death to one person and at least$2,000,000 due to bodily injury or death to two or more persons. r Dated this 2Qr`day of �f-t,L&r-y' 20 1°I Note: Access to school facilities may not be granted until all requirements of this ap lication are c mpi to nd approved by the school district and/or designee. {,`'��ark.. C11n ��� n CI Name of Individual/Organ zatlonrfeam Person Authorized to Sign Title Caere MAel w*te• Distnct Business Office School Principal 4260 F Yellow: Orgenlzation/Team Pink Principal Revised 3/2011 Self-Insured Coverage Document # CT- 20 1 9 WA " cities Insurance Authority WCIA Coverage Document#CT-2019 Page 2 WASHINGTON CITIES INSURANCE AUTHORITY Self-Insured Coverage Document CT-2019 January 1,2019 to January 1,2020 12:01 am Pacific Standard Time LIMITS/ULTIMATE NET LOSS: SELF-INSURED LAYER LIMIT: $4,000,000 PER OCCURRENCE REINSURED LAYER GEM: $3,000,000 PER OCCURRENCE REINSURED LAYER Argonaut Insurance Company: $8,000,000 PER OCCURRENCE AND $8,000,000 AGGREGATE PER MEMBER REINSURED LAYER Allied World Assurance Company, Inc.: $5,000,000 PER OCCURRENCE AND $5,000,000 AGGREGATE PER MEMBER TOTAL LIMIT: $20,000,000 PER OCCURRENCE, subject to aggregates and sub-limits below and in Section I.D,and Section I.E in the WCIA Joint Protection Program. SPECIFIC AGGREGATE LIMITS/SUB-LIMITS: $4,000,000 per occurrence limit and$4,000,000 annual aggregate per Member applying to Terrorism. $5,000,000 per occurrence limit and$5,000,000 annual aggregate limit per member for Errors or Omissions Coverage arising out of the operations, ownership, maintenance or use of any airport. $5,000,000 per occurrence limit and$5,000,000 annual aggregate limit per member for any liability arising out of Land-Use Planning and Land-Use Regulation,zoning, and any other land use and permitting process. DESCRIPTION OF COVERAGE: General Liability,Automobile Liability, Stop-Gap Coverage, Errors or Omissions Liability, Employee Benefits Liability and Employment Practices Liability Coverage. LIMITS OF LIABILITY FOR ALL COVERAGE: The Limits/Ultimate Net Loss stated herein and the rules below set the maximum the Authority will pay regardless of the number of: a. members, b. claims made or lawsuits brought, or c. persons or organizations making claims or bringing lawsuits. TERRITORY:This coverage applies to General Liability,Automobile Liability, Stop-Gap Coverage, Errors or Omissions Liability, Employee Benefit Liability and Employment Practices Liability occurring anywhere in the United States of America, its territories and possessions or Canada. Members covered by this agreement include the following and new members approved by the Executive Committee during the Coverage Year; members of the Large Deductible Program have their deductible levels listed by their names: A Regional Coalition for Housing (ARCH) LOTT Clean Water Alliance Aberdeen Mabton Anacortes Mason County Emergency Communications Arlington (MACECOM) Auburn Maple Valley Bainbridge Island Marysville Fire District Battle Ground McCleary Benton City Medical Lake Benton County Emergency Services(BCES) Medina Bonney Lake Mercer Island Bothell Metropolitan Park District of Tacoma ($25,000) Brewster Mill Creek Brier Millwood Burien Milton Burlington Monroe Camas Monroe Transportation Benefit District Cashmere Moses Lake($25,000) Centralia Mount Vernon Chehalis Mountlake Terrace Chelan Mukilteo Cheney Multi Agency Communications Center(MACC 911) Clark Regional Emergency Services Agency(CRESA) Newcastle Clarkston Normandy Park Cle Elum Normandy Park Metropolitan Park District Clyde Hill North Bonneville Coupeville Northshore Utility District Covington NW Incident Management Team Cowlitz 911 Oak Harbor Cowlitz-Wahkiakum Council of Governments Ocean Shores Des Moines Olympia Des Moines Pool Metropolitan Park District Olympia Metropolitan Park District Duvall Olympia Transportation Benefit District Eastside Public Safety Communications Agency Olympic View Water and Sewer District (EPSCA) Othello eCity Gov Alliance Pasco Edgewood PENCOM Edmonds Port Angeles($50,000) Ellensburg Port Townsend Elma Poulsbo Enumclaw Pullman Everson Pullman Metropolitan Park District Ferndale Pullman-Moscow Regional Airport Board Fife Puyallup($100,000) George Richland Goldendale Ridgefield Grandview Sammamish Grays Harbor Communications Center, E9-1-1 Seattle Southside Regional Tourism Authority Hoquiam Sequim Issaquah Shelton Jefferson County 911 Shelton Metropolitan Park District Kelso Shoreline Kenmore Silver Lake Water&Sewer District Kennewick Skagit 911 Kirkland Skagit Council of Governments Kitsap 911 Public Authority Snohomish Kitsap Regional Coordinating Council (KRCC) Snohomish County 911 La Conner Snoqualmie Lacey Soap Lake Lake Forest Park South Correctional Entity(SCORE) Lake Stevens South Sound 911 Lakewood Spokane Regional Emergency Communications Leavenworth Spokane Valley Long Beach Stanwood Longview Steilacoom WCIA Coverage Document#CT-2019 Page 4 Sumner Warden Sunnyside Washougal Three Rivers Regional Wastewater Authority Washington Cities Insurance Authority Thurston 9-1-1 Communications Washington Multi-City Business License and Tax Thurston Public Utility District Portal Agency Thurston Regional Planning Council (TRPC) Water Operating Board Toppenish West Richland Tukwila($25,000) Westport Tukwila Pool Metropolitan Park District WHITCOM 911 Tumwater William Shore Memorial Pool District Union Gap Woodinville University Place Woodway Valley Communications Center Yakima Valley Conference of Governments Valley Regional Fire Authority Yarrow Point Walla Walla Zillah Walla Walla Valley Metropolitan Planning Organization This document is not an insurance policy. The Washington Cities Insurance Authority(Authority) is not an insurance company. This document is an agreement by and between the Authority and its members to pay all covered losses subject to the limits and other terms, exclusions and conditions of this Agreement and any addenda attached. This document is to be construed and enforced under the law of the State of Washington. In consideration of the assessments paid by the members,this Agreement provides the following coverages: I. COVERAGE AGREEMENTS A. GENERAL&AUTOMOBILE LIABILITY COVERAGE 1. Coverage In consideration of the assessment herein provided, the Authority hereby agrees,subject to the limitations,terms,exclusions and conditions hereinafter mentioned,to pay on behalf of the member all sums which the member shall be obligated to pay by reason of liability: a. imposed upon the member by law; or b. assumed under contract or agreement by the member and/or any officer,director, official, or employee of the member,while acting in his or her capacity as such; c. for damages, direct or consequential and expenses,all as more fully defined by the term"ultimate net loss"on account of: i. personal injury, ii. property damage, iii. advertising liability, caused by or arising out of an occurrence during the coverage period.The coverage for the liability assumed under contract in I.A.1.b. above shall be limited to the terms, conditions, limitations and exclusions in the Coverage Document and the Liability Joint Protection Program document. "Damages"as used in this section and this Agreement, do not include punitive or exemplary damages or fines or penalties or any similar relief awarded against the member. 2. Defense and Settlement of Covered Claims Subject to the limits and other terms, exclusions and conditions of this Agreement,for any claim covered by this Agreement and properly tendered to the Authority,the Authority shall have the absolute and unrestricted right and duty to select legal counsel to defend the member against the claim and pay the costs of the selected defense counsel and;further, shall have the absolute and unrestricted right to settle any covered claim within the limits of the provided coverage. The Authority shall have no obligation or duty to pay for the defense costs of a member for any uncovered or excluded claim.