WESTERN ROOFING EXPO 2010
PROOF OF INSURANCE/ WSRCA’s 36th Annual Convention & Tradeshow
June 20-23, 2010
WAIVER OF LIABILITY FORM Paris-Las Vegas Hotel & Casino
Las Vegas, Nevada
Deadline: April 1, 2010
PLEASE NOTE: DO NOT SEND CERTIFICATES TO THE WSRCA OFFICE. PLEASE COMPLETE THIS
FORM AND HAVE YOUR CERTIFICATE ON SITE IN THE EVENT THAT IT IS NEEDED
Each exhibitor shall secure and maintain, at its own expense, the following insurance requirements and shall have evidence
of the necessary certificates of insurance (including additional insured endorsements and primary coverage endorsements) 3
on hand if called upon to present them at the Western Roofing Expo. Below, please check that you have obtained all of the
following required coverages to exhibit with the Western States RCA.
• NAME AND ADDRESS OF THE INSURED: Name of the exhibitor as stated on the Application for Exhibit Space must ap-
pear on the Certificate. Please note: Parent or Holding Companies may be listed as the insured, however, the exhibiting company
name must also be listed.
• COMMERCIAL GENERAL LIABILITY COVERAGE: Limits not less than $1,000,000 combined single limit for bodily
injury, personal injury and property damage.
• EFFECTIVE POLICY DATES: Must be valid through 11:59pm, Wednesday, June 23, 2010
• AUTOMOBILE LIABILITY COVERAGE: Coverages must be evidenced ONLY for those exhibitors driving or exhibiting
a vehicle on the tradeshow floor.
• WORKERS COMPENSATION COVERAGE: Bodily Injury by Accident Coverage for $100,000 per accident. Bodily Injury
by Disease Coverage with a $100,000 policy limit. Bodily Injury by Disease Coverage for $100,000 per employee.
• LIST OF ADDITIONAL INSUREDS: As bound by the Application for Exhibit Space, the Certificate of Insurance is to list
the Western States RCA, the City of Las Vegas, and the Paris-Las Vegas Hotel & Casino as the “Additionally Insureds.”
• WAIVER OF SUBROGATION: Personal Property (Current property forms generally automatically grant this waiver [without
an additional premium charge] if the waiver is required by a written contract [Application for Exhibit Space] between the insured
and the third party beneficiary of the waiver, and they are notified in writing of this contractual provision prior to any loss.)
• WAIVER OF LIABILITY: It is agreed that exhibitors will assume responsibility for any damages to the Paris-Las Vegas Hotel
& Casino and their own exhibits. The exhibitor further agrees that neither the Western States Roofing Contractors Association, nor
its employees, agents, or representatives shall be liable and that the exhibitor will save hold harmless and make no claims for any
reasons whatsoever including negligence, against the Western States Roofing Contractors Association, its employees, agents or
representatives for loss, theft, damage or destruction of goods or displays; nor for any accident or injury to or death of the exhibitor
or the exhibitor’s employees, agents or representatives while in the Western States Roofing Contractors Association quarters; nor
for any damage of and nature or character, including any damage to his business by reason of the failure to provide space for the
exhibit or the removal of the exhibit; nor for any other action of employees, agents or representatives of this Association; nor for
failure to hold the exhibit as scheduled; nor for any causes beyond control of Western States Roofing Contractors Association,
the Paris-Las Vegas Hotel & Casino, or the exhibit service contractor that may render any exhibit area unusable.
Company Booth #
Contact Name Signature Date
Please Return to: Western States RCA • Attn: Joel Viera • 465 Fairchild Drive, Suite #210 •
Mountain View, CA 94043 • Phone: (650) 938-5441 • Fax: (650) 938-5407 • Email: firstname.lastname@example.org