AG 05-138 - CIAW-CITIES INSURANCE OF WA
DATE IN:
I DATE OUT: I TO:
CITY OF FEDERAL WAY LAW DEPARTMENT
1.
REQUEST FOR CONTRACT PREPARATION/DOCUMENT REVIEW/SIGNATURE ROUTING SLIP
2.
4.
5.
6.
ORIGINATING DEPT./DIY: -\ \f\O....f\ U
ORIGINATING STAFFPERSON:~ J......re1l
TYPE OF DOCUMENT REQUESTED (CHECK ONE)
o PROFESSIONAL SERVICE AGREEMENT
o MAINTENANCE/LABOR AGREEMENT
o PUBLIC WORKS CONTRACT
o SMALL PUBLIC WORKS CONTRACT
EXT:
3. DATE REQ. BY:
o SECURITY DOCUMENT (E.G. AGREEMENT &
PERF/MAIN BOND; ASSIGNMENT OF FUNDS IN LIEU OF BOND)
o CONTRACTOR SELECTION DOCUMENT
(E.G" RFB, RFP, RFQ)
o CONTRACT AMENDMENT
o CDBG
)<OTHER
AGff:
(LESS THAN $200,000)
o PURCHASE AGREEMENT)
(MATERIALS, SUPPLIES, EQUIPMENT)
o REAL ESTATE DOCUMENT
PROJECT NAME: ~ --ftSOC1ti,/-f., 1je~ber Are.eMenf-.
NAMEOFCP~T~TOR~~~S ~)<aX'C-' M W~~
ADDRESS: """\6\ \ A \,U'\ z.3 H\) TELEPH,', "'l\~;Wry
SIGNATURE NAME: _~ ___ TITLE_~~
7. ATTACH ALL EXHIBITS AND CHECK BOXES 0 SCOPE OF SERVIC ES 0 ALL EXIIIUITS REFERENCED IN DOCUMENT
o INSURANCE CERTIFICATE 0 DOCUMENT AUTHORIZING SIGNATURE
8.
9.
10.
11.
TERM: COMMENCEMENT DATE:
COMPLETION DATE:
TOTAL COMPENSATION $.~", (INCLUDE EXPENSES AND SALES TAX, IF ANY)
(IF CALCULATED ON HOURLY LABOR CHARGE -ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES)
REIMBURSABLE EXPENSE: 0 YES 0 NO IF YES, MAXIMUM DOLLAR AMOUNT: $
IS SALES TAX OWED 0 YES 0 NO IF YES, $__._"._.__,_
PAID BY: 0 CONTRACTOR 0 Cn
CONTRACT REV JEW
o PROJECT MANAGER
o DIRECTOR
o RISK MANAGEMENT
o LAW
INITIAL/DATE APPROVED
INITIAL/DATE APPROVED
CONTRACT SIGNATURE ROUTING
o LAW DEPARTMENT
k"CITY MANAGER
o CITY CLERK
":)i1 SIGN COpy BACK TO ORGfH' A'fIHO DEPT.
J( ASSIGNED AG# [)'7-13 fJ
o PURCHASING: PLEASE CHARGE TO:
INITIALIDATE APPROVED
INITIAL/DATE APPROVED
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COMMENTS I" \
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CITIES INSURANCE ASSOCIATION
OF WASHINGTON
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JUN ,,4,__
ASSOCIATE MEMBER AGREEMENTC"'Nf'If't 3 ,0 2005
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WHEREAS, the Cities Insurance Association of Washington is entitled
under RCW 48.62 to include other municipal and governmental entities in the
Cities Insurance Association of Washington; and
WHEREAS, the Cities Insurance Association of Washington Board of
Directors has approved by Resolution the inclusion of Associate Membership to
the Cities Insurance Association of Washington subject to the Board's individual
approval of each City; and
WHEREAS, the undersigned City is entitled under RCW 48.62 to
participate in an insurance cooperative and by Resolution has chosen to apply
for Associate Membership, the Cities Insurance Asso iation of Washington,
(hereinafter referred to as "ClAW"), and the' . f' \ City of-
\L\r'"\Ca County, (hereinafter referred t as "City" agree to the ~ lowing:
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1. The City agrees to provide all application information to the ClAW for
consideration of membership.
2. The City agrees to pay all premiums when due as per statements
issued by the ClAW on a direct basis to the ClAW
3. The City agrees to retain the services of a licensed insurance broker
within the State of Washington to serve as a Service Representative or
utilize the ClAW to provide these same services.
4. The Cities Insurance Association of Washington agrees to provide
General Liability, Public Officials Liability, Automobile Liability,
Property, Boiler and Fidelity Coverages as per the policy overviews
and accompanying policy provided to the City.
5. The ClAW agrees to provide risk management services to the City and
the City agrees to utilize risk management recommendations as
prudent.
\
Associate Member Agreement
h:\data\!cities\lcitleslassocite.doc
9/9/96
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6. The City agrees to report all losses regardless of monetary amount or
question of liability as soon as possible through the assigned Service
Representative to the ClAW.
7. The City agrees to pay deductibles as per the policy overviews and the
assessment.
8. The City and the ClAW agree the City's membership in the CIAW'is an
Associate Membership and the City shall not have any ownership in
the assets of the ClAW nor shall the City be responsible for any
shortfalls in claims reserves, if any, experienced by the ClAW.
9. The City is subject to all terms and conditions specified for Associate
Members in the Interlocal Agreement and By-Laws of the Cities
Insurance Association of Washington.
DATED this 29 ~ day of --.T1"j~~ , 200.s-
City
By:
By:
ity Representative Signature
l)ert..fc M~~~~fO"
AUt54~.\ Ci-'j ~
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Associate Member Agreement
9/9/96