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HomeMy WebLinkAboutTUP2022-3175SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 rights to the certificate holder in lieu of such endorsement(s). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY X This certificate of insurance does not affirmatively or negatively amend, extend, or alter the coverage afforded by the insurance policy. Included Included ZAI X X 1,000,00001/03/2022 01/03/2023 FLM1219265-01 Excluded Excluded Fax No.Phone No. Jaimee.Goehring@sleepersewell.com (972) 419-7555 Jaimee Goehring (972) 419-7500 09/08/2022 Certificate Holder is named as an Additional Insured as their interests may appear. Grapevine City Hall - Second Floor 200 S. Main Street Grapevine, TX 76051 United States Of America X ZAI - Zurich American Insurance Company Coverage Location:United States & Canada All coverages expire at 12:01 a.m. Standard Time. Covered Events As Declared to and Accepted by Carrier * The actual event dates may be limited. Please review the Scheduled Events form attached to this certificate. ZAI X X X XX 1,000,000 500,000 2,000,000 Host Liquor 5,000 1,000,000 01/03/2022 01/03/2023 FLM1219265-01 1,000,000 Dr Joe Dispenza dba Encephalon, Inc 13115 Vail Cutoff Road SE Rainier, WA 98576 Fax No.(253) 212-6632Phone No. Max Aggregate Max per Auto 16535 ZAI See Attached01/03/2022 01/03/2023Inland Marine FLM1219265-01 Sleeper Sewell Insurance Services 12400 Coit Rd., Suite 1100 Dallas, TX 75251 (972) 419-7555Fax No.(972) 419-7500Phone No. 986761 APM-CERT-DETAILS 1009 Certificate Number 986761 ADDITIONAL COVERAGE DETAILS DATE (MM/DD/YY) 09/08/2022 INSURED Dr Joe Dispenza dba Encephalon, Inc The following is attached to and made part of certificate number 986761. Policy Details Coverage Limit Deductible Inland Marine Company: Zurich American Insurance Company Policy Number: FLM1219265-01 *Period: 01/03/2022 - 01/03/2023: 365 Day(s) Equipment, props, sets, wardrobe (rented) 25,000 1,000 Equipment, Props, Sets, Wardrobe (owned) Excluded Rented Furs, Jewelry, Art & Antiques Coverage Excluded Extra Expense Excluded Third Party Property Damage 1,000,000 2,500 Office Contents Excluded Business Income/Extra Expense Excluded Hired/Non-Owned Physical Damage-Aggregate Excluded Hired/Non-Owned Physical Damage-Per Vehicle Excluded Rental Cost Reimbursement Excluded EDP EDP (Electronic Data Processing Equipment) Excluded Limited Computer Virus Coverage Excluded Accounts Receivable Excluded Valuable Papers and Records Excluded Money & Securities Excluded Waiver of Subrogation Excluded Coverage Extension Endorsement Coverage Extension Endorsement Excluded Worldwide Coverage Excluded Terrorism Included General Liability Company: Zurich American Insurance Company Policy Number: FLM1219265-01 *Period: 01/03/2022 - 01/03/2023: 365 Day(s) General Aggregate 2,000,000 Products / Completed Operations 1,000,000 Personal / Advertising Injury 1,000,000 Each Occurrence 1,000,000 Fire Legal 500,000 Medical Payments 5,000 Blanket Additional Insureds (other than city/special certs & waivers) Included City / Other Special Certificates Included Waiver of Subrogation Included Employee Benefits Liability - Policy Aggregate Excluded Employee Benefits Liability - Each Claim Excluded Host Liquor Included Liquor Liability-Aggregate Excluded Liquor Liability-Each Common Cause Limit Excluded Abuse & Molestation-Aggregate Excluded *All coverages expire at 12:01 a.m. Standard Time. APM-CERT-DETAILS 1009 Certificate Number 986761 Policy Details Coverage Limit Deductible Abuse & Molestation-Each Claim Excluded Stop Gap Liability Excluded Terrorism Included Scheduled Events Certificate Number: 986761 Page 1 of 1ABANEV-SCHD(05/06) Event Type Venue Dates Attendees Dallas Week Long with Dr. Joe Dispenza Instructional Classes Gaylord Texan Resort & Convention Center 1501 Gaylord Trail Grapevine, TX 76051 09/29/2022 - 10/01/2022 at 12:01 am (Setup) 10/01/2022 - 10/08/2022 at 12:01 am 12,600  Spectators   Page 1 of 2 SCHEDULE OF FORMS DATE (MM/DD/YY) 09/08/2022  APA-CERT-FORMLIST 0914  Certificate Number: 986761  Insured:Dr Joe Dispenza dba Encephalon, Inc This Schedule of Forms is attached to and made part of certificate number 986761, as of 09/08/2022 at 12:31 PM PT, and lists the forms included in the policy(s) and subsequent endorsement (s) at the time this certificate was issued.     Form # Ed. Name Special Event Package Notices U-GU-319-F 0109 Important Notice - In Witness Clause U-GU-874-A 0611 Notice of Disclosure for Agent and Broker Compensation UGU873ACW 0611 Disclosure Statement U-GL-1197-A CW 0104 Asbestos Exclusion Endorsement UGU742ACW 0906 Advisory Notice To Policyholders - Change in Carrier U-GU-1191-ACW 0315 Sanctions Exclusion Endorsement Common UGU727ACW 0806 Commercial Insurance Policy UGUD310A 0193 Common Policy Declarations UGU619ACW 1002 Schedule of Forms and Endorsements UGU621ACW 1002 Schedule Of Named Insured(s) UGU618ACW 1002 Schedule Of Locations IL0146 0810 Common Policy Conditions - Washington UABI101ACW 0117 Definition Of Employee UAB100ACW 0117 Minimum Earned Premium Endorsement IL0003 0908 Calculation of Premium U-GU-630-ECW 0120 Disclosure of Important Information Relating to Terrorism Risk Insurance Act Inland Marine UABMD104ACW 0117 Commercial Inland Marine Declarations Entertainment Program UGU619ACW 1002 Schedule of Forms and Endorsements CM0001 0904 Commercial Inland Marine Conditions UABM133AWA 0117 Common Conditions, Exclusions And Definitions - Washington UABM105ACW 0117 Miscellaneous Equipment Coverage Form UABM106ACW 0117 Props, Sets And Wardrobe Coverage Form UABM109ACW 0117 Third Party Property Damage Coverage Form UABM103ACW 0117 Loss Payable Endorsement UABM128ACW 0117 Excluded Property Endorsement UABM100ACW 0117 Stunt, Animal Exposure And Pyrotechnic Exclusion CM0107 0619 Washington Changes UABM184AWA 0417 Washington Amendatory U-GU-767-BCW 0115 Cap on Losses From Certified Acts of Terrorism U-GU-616-ACW 1002 Schedule of Taxes, Fees and Surcharges General Liability UABLD100BCW 0119 Commercial General Liability Coverage Part Declarations UGU619ACW 1002 Schedule of Forms and Endorsements UABI110ACW 1020 Schedule of Events CG0001 0413 Commercial General Liability Coverage Form CG2011 1219 Additional Insured - Managers of Lessors of Premises CG2012 1219 Additional Insured - State or Governmental Agency or Subdivision or Political Subdivision - Permits or Authorizations CG2026 1219 Additional Insured - Designated Person or Organization CG2028 1219 Additional Insured - Lessor of leased equipment CG2404 1219 Waiver of Transfer of Rights of Recovery Against Others to Us U-GL-1327-BCW 0413 Other Insurance Amendment - Primary And Non- Contributory UABL128AWA 0117 Additional Insured - Owners Or Lessees Scheduled Person Or Organization Primary and Noncontributory Coverage - Washington UABL121ACW 0117 Limited Stationary Aircraft Coverage CG2106 0514 Exclusion - Access or Disclosure of Confidential or Personal Information and Data-Related Liability - With Limited Bodily Injury Exception U-GL-1171-B-CW 0719 Fungi Bacteria Exclusion U-GL-1199-A 0404 Asbestos Exclusion Endorsement U-GL-1178-A-CW 0703 Asbestos Exclusion CG0197 1207 Washington - Employment Related Practices Exclusion U-GL-1517-BCW 0413 Collection or Distribution of Material or Information in Violation of Law Exclusion UABL153AWA 1019 Annual Event Rating Schedule - Washington UABL151ACW 1019 Concessionaire/Exhibitor Rate Schedule UABL152ACW 1019 Certificate Rating Schedule UABL131AWA 0117 Non-Performing Animal Exclusion - Washington UABL102ACW 0117 Property Damage To Rented Premises Exclusion UABL129AWA 0117 Assault And Battery Exclusion - Washington UGL1250ACW 0905 Abusive Act Liability Exclusion UABL122ACW 0117 Newly Acquired Or Formed Entity Exclusion UABL107ACW 0117 Exclusion - Insureds Conducting Media, Entertainment, Or Internet Type Operations UABL130AWA 0117 Informational Content Exclusion - Washington UABL135AWA 0117 Media Content Exclusion - Washington UABL137ACW 0117 Cross Suits Exclusion UABL138ACW 0117 Personal And Advertising Injury - Exclusion Of False Arrest, Detention, Imprisonment, Libel, Slander, Right Of Privacy, Advertising Idea, And Copyright, Trademark Or Trade Secret UABL133ACW 0117 Partnership, Joint Venture And Limited Liability Company Limitation UABL106AWA 0117 Unscheduled Production, Presentation Or Event Exclusion - Washington UABL103AWA 0117 Stunt, Pyrotechnic And Animal Exposure Exclusion - Washington UABL144AWA 1019 Event Conditional Exclusion - Washington Disclaimers Page 2 of 2 SCHEDULE OF FORMS DATE (MM/DD/YY) 09/08/2022  APA-CERT-FORMLIST 0914  Certificate Number: 986761  Insured:Dr Joe Dispenza dba Encephalon, Inc This Schedule of Forms is attached to and made part of certificate number 986761, as of 09/08/2022 at 12:31 PM PT, and lists the forms included in the policy(s) and subsequent endorsement (s) at the time this certificate was issued.     Form # Ed. Name CG2132 0509 Communicable Disease Exclusion UABL146AWA 1019 Unscheduled Products Exclusion - Washington UABL145AWA 1019 Hazardous Activities, Pyrotechnic Activities and Animal Exposure Exclusion - Washington UABL147AWA 1019 Loss Arising Out of Participation in a Sports or Athletic Event, Competition, Contest or Exhibition Exclusion - Washington UABL143AWA 1019 Moshing Exclusion - Washington UABL150AWA 1019 Camping Conditional Exclusion - Washington CG0181 0508 Washington Changes IL0198 0908 Nuclear Energy Liability Exclusion Endorsement (Broad Form) IL0123 1113 Washington Changes - Defense Costs UABL105AWA 0117 Commercial General Liability Changes - Washington U-GU-767-BCW 0115 Cap on Losses From Certified Acts of Terrorism U-GU-616-ACW 1002 Schedule of Taxes, Fees and Surcharges Automobile U-CA-531-B 0208 Notice Regarding Terrorism Premium (for Commercial Automobile Ins) UCAD600C 0414 Business Auto Declarations UGU619ACW 1002 Schedule of Forms and Endorsements UABA100ACW 0117 Extended coverage For Scheduled Events, Presentations and Productions CA0001 1013 Business Auto Coverage Form UABA120AWA 0117 Additional Insured - Owners Or Lessees Scheduled Person Or Organization - Washington UABA125AWA 0617 Production Stunt Or Pyrotechnic Exclusion - Washington CA0135 1013 Washington Changes IL0123 1113 Washington Changes - Defense Costs IL0198 0908 Nuclear Energy Liability Exclusion Endorsement (Broad Form) CA2048 1013 Designated Insured UABA104AWA 0117 Business Auto Changes - Washington U-GU-616-ACW 1002 Schedule of Taxes, Fees and Surcharges This Certificate of Liability Insurance includes the Type of Insurance, Limits, and Schedule of Forms in effect as of  09/08/2022 at 12:31 PM PT. It does not affirmatively or negatively amend, extend, or alter the coverage afforded by the insurance policy nor confer any rights upon the certificate holder. You may be required to request an updated certificate in the event of subsequent policy modifications. The information included in this certificate that has been provided by Abacus Insurance Brokers, LLC is for your information only, and does not create a contract or agency relationship between the certificate holder or any insured and Abacus Insurance Brokers, LLC. By accepting this certificate the certificate holder acknowledges that Abacus Insurance Brokers, LLC is not the agent of the certificate holder or any insured, but is solely the agent of the listed carrier(s). Abacus Insurance Brokers, LLC makes no representation whether the coverages listed herein are appropriate for the certificate holder or any insured. Please review the listed coverages carefully and direct any questions to your broker. For a complete listing of coverages, terms, conditions and exclusions, please view the referenced Policy(s). Certificate Verification  APA-CERTVER 0917 Certificate Number: Page 1 of 1 Date (MM/DD/YYYY)  Insured:  Abacus provides an efficient website lookup tool for certificate holders to verify   the authenticity of certificates of insurance.    1.Navigate to the website and input the verification code OR Scan the QR code. 2.The actual certificate issued through the Abacus Platform will download. 3.Compare the details of the downloaded certificate to the certificate presented by the client. About Certificates Issued through the Abacus.net Platform  Abacus requires that all certificates be issued through the Abacus Platform.  Certificates issued outside of the Abacus Platform are invalid. Certificates may be issued through the Abacus Platform by either the named insured (if registered through the Abacus Platform) or their Abacus registered insurance broker. Certificates with any stray marks, cross outs or alterations of any sort are invalid. Each certificate is numbered and correlates to the document issued through the Abacus Platform. Website Verification Code  986761 09/08/2022 Dr Joe Dispenza dba Encephalon, Inc 0T0CLT5OE1www.abacus.net/verify-certificate