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AG 13-026�TUx�v To: �61,i1,� � ExT: '2`1 �� � CITY OF ��DERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT./DIV: �� � 2. ORIGINATING STAFF PERSON: 1 � � \ EXT: v� �lZ 3. DATE REQ. BY: I v y I r� �.te�d. -(�.P�..I�.c� 4. TYPE OF DOCUMENT (CHECK ONE): n0 ���-�- O CONTRACTOR SELECTION DOCUMENT (E.G, RFB, RFP; RFQ) � I�I � 3 ❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT ❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT O GOODS AND SERVICE AGREEMENT ❑ HUMAN SERVICES / CDBG D REAL ESTATE DOCUMENT ❑ SECURITY DOCLIMENT (�.c. sorm xEEt.a,TEn noctnv¢rrrs) ❑ ORDINANCE ❑ CONT'RACT C� OTHER � ❑ RESOLUTION O INTERLOCAL 5. PROJECT NAME: �,yr t l� N lk..�-l� -f- �G��� � �� - - 6. NAME OF CONTRACTOR: ADDRESS: E-MAIL: SIGNATURE NAME: TELEPHONE FAX: TITLE 7. EXHIBITS AND ATTACHMENTS: O SCOPE, WORK OR SERVICES ❑ COMPENSATION � INSURANCE REQUIREMENTS/CER'I'IFICATE ❑ ALL OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIItED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS 8. TERM: COMMENCEMENT DATE: �2Co r i3 LO QWl COMPLETION DATE: `! �o �[�j Zb,rt,,r 9. TOTAL COMPENSATION $_� (INCLUDE EXPENSES AND SALES TAX, IF ANY� (IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLAYEES TITLES AND HOLIDAY RATES) REIMBURSABLE EXPENSE: ❑�s ❑ 1vo IF YES, MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX OWED ❑ YES ❑ NO IF YES, $ PAID BY: O CONTRACTOR � CTTY ❑ PURCHASING: PLEASE CHARGE TO: 10. DO ENT/CONTRACT REVIEW I1�TITIAL / DATE REVIEWED I1�iITIAL / DATE APPROVED ROJECT MQNAGER `�i/� � � (1 � �j � � �� �� DIRECTOR —T� � � LAW I � �� �tJi3 � t �2S�ZOt3 • -' — s �iL� h�rs w ,�,�-- i•2 • r 11. COLTNCILAPPROVAL �IF APPLICABLE� COMM E APPROV DA ' COUNCILAPPROVAL ATE: 12. CONTRACT SIGNATURE ROUTING ❑ SENTTO VENDOR/CONTRACTOR DATE SENT: DATE REC'D: ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBTTS ❑ LAW DEPARTMENT �( SIGNATORY (Clvt olt nu�Crott) J� CITY CLERK �I ASSIGNED AG# �I SIGNED COPY RETURNED INITI DATE SIGNED . ��m i � �i�.� AG# �� - DZ �D DATE SENT: I ' �JD � j � �„� � �,-.�....,, „ �. _ , . i . � � INDEMNIFICATION AND INSURANCE AGREEMENT This Indemnification and Insurance Agreement ("Agreement") is dated effective the later date indicated below with the signature. The parties ("Parties") to this Agreement are the City of Federal Way, a Washington municipal corporation ("City") and JFranciscan Health S sY tem, a("Health Care Provider"). A. The Health Care Provider wishes to contribute services for the Federal Way Family Health & Safety Fair on January 26, 2013; and B. The City wishes to cooperate by allowing the use of the Federal Way Community Center, 876 S. 336�` Street, Federal Way, Washington. Vendor space is $50. NOW, THEREFORE, the Parties agree as follows: 1. Indemnification. In consideration of the City authorizing its use of the Federal Way Community Center, the Health Provider agrees to indemnify and hold the City, its elected officials, officers, employees, agents, volunteers, sponsors, contributors and donors harmless from any and all claims, demands, losses, actions and liabilities (including costs and all attorney fees) to or by any and all persons or entities, including, without limitation, their respective agents, licensees, or representatives, arising from, resulting from, or connected with this Agreement or the use of the Federal Way Community Center or relating to the Family Health & Safety Fair to the extent caused by the acts, errors or omissions of the Health Care Provider, its partners, shareholders, agents, employees, invitees or by the breach of this Agreement. 2. Insurance. The Health Care Provider agrees to submit a Certificate of Insurance evidencing Commercial General Liability in the amount of no less than $1,000,000 naming the City of Federal Way as additional insured and Professional Liability insurance in the amount of no less than $1,000,000. The Certificate should be presented with the executed Agreement no later than Friday, January 11, 2013. Failure to submit proof of such insurance and execute this Agreement shall prohibit the Health Care Provider from participating in the Federal Way Community Center Health Fair on January 11, 2013. 3. Citv Contact. Submit the certificate of insurance and the executed Agreement no later than Friday, January 11, 2013, to: Kimberly 5helton, Fitness/Athletic Coordinator City of Federal Way 876 S. 333`d St. Federal Way, WA 98003 CITY OF FEDERAL WAY / / . � ��L<< , � , �' - . . Date: ���..r 2�?�� 3 Qi� ATTEST Carol McNeilly, C C, City erk HEALTH CARE PROVIDER �. � :�,�/ ,. - a Kara Ward (Printed Name and Title) Franciscan Health Svstem (Organization Name) 1142 Broadway Ste 300 Tacoma, WA 98402 (Address) 253-382-3850 (Phone) Date: 1/10/12 STATE OF WASHINGTON ) ) ss. COUNTY OF p; ���� ) � On this day personally appeared before me � o� p[ �.�.� J , to me known to be the Aalm : n; s�.- p�� of „ i •r, that executed the foregoing instrument, and acknowledged the said instrument to be the free d voluntary act and deed of said corporation, for the uses and purposes therein mentioned, and on oath stated that he/she was authorized to execute said instrument and that the seal affixed, if any, is the corporate seal of said corporation. ,� - - : ; : N4TARy C , _ ..� • �.. ��. tn�l official seal this / o r�f day of �' a � �., y , 2013 . ► '� A �Iy � � = Notary's signature � • . : � # Notary's printed name %a � �, .� R - m. /a/� -� �,;; Notary Public in and for the Stat of Washington. �?�,` My commission expires y � . K:Wgreements�Parks�2010�IIealth Fair Indem -2- FIRST INITIATIVES INSURANCE, LTD Grand Pavilion Commerciai Centre, Suite 6 P.O. Box 10073 Grand Cayman, KY1-1001, Cayman Islands (345) 943-2645, Fax (345) 943-2646 Email: firstinitiatives@cmi.ky THIS IS TO CERTIFY TO NAME AND ADDRESS OF CERTIFICATE HOLDER: CITY OF FEDERAL WAY ATTN: KIMBERLY SHELTON, FITNESS/ATHLETIC COORDINATOR 876 S. 333RD STREET FEDERAL WAY, WA 98003 DATE OF CERTIFICATE ISSUANCE: January 9, 2012 ORIGINAL DATE OF ISSUANCE January 9, 2012 CERTIFICATE OF SELF-INSURANCE That the described self-insurance coverages as provided by the indicated policy and issued by the company has been issued to: Named Insured: ST FRANCIS HOSPITAL Address: 34515 NINTH AVENUE SOUTH FEDERAL WAY, WA 98003 The Policy identified below by a policy number is in force on the date of Certificate issuance. Seli-Insurance is aNaded or�y with respect to those coverages (a which a specific kmit oi liabi�ry has been entered and is subject to all the terms of Ihe Policy having re(erence thereto. This Cer6ficate o( SeIF-Insurance neither a(firmaGvely na negaGvely amends, extends or aUers the coverage afforded under arry policy iden6fied herein. POLICY NUMBER POLICY PERIOD FIPR00712 EFF. 07101112 EXP. 07101h3 TYPE OF SELF-INSURANCE DESIGNATED BELOW COVERAGES LIMITS OF LIABILITY BODILY INJURY, PROPERTY DAMAGE, PERSONAL INJURY LIABILITY & COMMERCIAL GENERAL LIABIUN MISCELIANEOUS PROFESSIONAL LIABILIN 10 000 000 Each claim HOSPITAL PROFESSIONAL LIABILITY AS DESCRIBED 10 000 000 Each daim 585,000,000 Shared A ate Claims made coverage. Policy reuoactive date is: July 1, 2002 R COVERAGES ID NUMBER: 46056 THE CITY OF FEDERAL WAY IS ADDED AS ADDITIONAL INSURED, SUBJECT TO THE TERMS AND CONDITIONS OF 7HE POLICY, ATIMA, REGARDING CONTRIBUTING SERVICES FOR THE FEDERAL WAY FAMILY HEALTH & SAFETY FARE TO BE HELD ON JANUARY 26, 2013. Cancellation: Should amr of the above described policies be cancelled befare the expirapon date thereof, the issuing company will endeavor to maa 30 days wriuen noGce to the above named cerlilicate holder, but failure to mail such noUce shaA impose no obligation or liability of any kind upon the company. �MM� ,s "-^� Authorized Representative