Loading...
AG 13-027TO: EXT: CITY OF ��DER.AL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT./DIV: � � � 2. ORIGINATING STAFF PERSON: 1 ;�VIQ�I � EXT: V� J� 3. DATE REQ. BY: I'�% I� �.�mc�. -�-�e- I�c� 4. TYPE OF DOCUMENT (CHECK ONE): n0 ���-�- ❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP;-RFQ) +]� j' 3 O PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT I l ❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT ❑ GOODS AND SERVICE AGREEMENT ❑ HUMAN SERVICES / CDBG 6. O REAL ESTATE DOCUMENT ❑ ORDINANCE O CONTRACT ENDMENT � � OTHER ( ❑ SECURITY DOCUMENT (�.c. sorro xEEC,nTSn nocun�x�rs� ❑ RESOLUTION ❑ INTERLOCAL t � � PROJECT NAME: __�,j/V� t � W �-i� 'i� ��; �Y� �� ��. V . /l �. � . . ,., .. . _ _ e � _ � .. . _ NAME OF CONTRACTOR: ADDRESS: E-MAIL: SIGNATURE NAME: TELEPHONE FAX: TITLE 7. EXHIBITS AND ATTACHMENTS: ❑ SCOPE, WORK OR SERVICES ❑ COMPENSATION � INSURANCE REQUIItEMENTS/CERTIFICATE ❑ ALL OTI-IER REFERENCED EXHIBTTS ❑ PROOF OF AUTHORTTY TO SIGN ❑ REQUIltED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS 8. TERM: COMMENCEMENT DATE: I�2.Co � t 3 LO aU� COMPLETION DATE: I 1 Lt'o � t 3 Z e,,t,i 9. TOTAL COMPENSATION $ � (INCLUDE EXPENSES AND SALES TAX, IF ANY� (IF CAI.CULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES) REIMBURSABLE EXPENSE: 0�s ❑ xo IF YES, MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX OWED ❑ YES ❑ NO IF YES, $ PAID BY: ❑ CONTRACTOR ❑ C1TY ❑ PURCHASING: PLEASE CHARGE TO: 10. DO ENT/CONTRACT REVIEW I1�TITIAL/DATEREVIEWED I1�TITIAL/DATEAPPROVED ROJECT MANAGER � � � � �� ��3 DIRECTOR �e-Ri ���'-{��,�� �1 LAW � ( � � �tI (3 � f �ZS��oi3 11. COUNCIL APPROVAL (� nrPLIC,e,Br.E) .iI�IJ : i t�!��.: ,�� f � 1 � 1 j1 Il �� tl �.ri..��ilt�.� !�, , � , � ,� , , .� • • •• � � + • 1 1 �_ �;• , �: 12. CONTRACT SIGNATURE ROUTING ❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D: ❑ ATTACH: SIGNATURE AUTHORTTY, INSURANCE CERTIFICATE, LICENSES, EXHIBTTS ❑ LAW DEPARTMENT �8( SIGNATORY (cM oR nmECTOx) j� CITY CLERK �ASSIGNED AG# SIGNED COPY RETURNED I1�1ITI DATE SIGNED �;,tYl 1-30 •�3 aG# _1��U2� DATE SENT: I •?Za • I.�j COMMENTS: s� �,(�j p j�.' Y �' ��� �.�v� � <��,,y'YbL'/ !�% �$i"P/v'i�/I(;�' j-. r���.. C: INDEMNIFICATION AND INSURANCE AGREEMENT This Indemnification and Insurance Agreement ("Agreement") is dated ef�'ective the later date indicated below with the signature. The parties ("Parties") to this Agreement aze the City of Federal Way, a Washington municipal corporation ("City") and Virginia Mason Medical Center, a Washington nonprofit corporation located at 1100 Ninth Avenue, Seattle, WA 98101("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`h Street, Federal Way, Washington. Vendor space is $50. NOW, THEREFORE, the Parties agree as follows: l. Indemnification. In consideration ofthe City authorizing its use ofthe 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 harmtess from any and a11 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 respeetive 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 and Professional Liability insurance in the amount of no less than $1,000,000. The Certificate should be presented with the executed Agreement no later than Friday, January 11, 2013. Failure to submit proof of such insurance and execute this Agreement shall prohibit the Health Care Provider from participating in the Federal Way Community Center Health Fair on January 26, 2013. 3. City Contact. Submit the certificate of insurance and the executed Agreenient no later than Friday, 3anuary l 1, 2013, to: Kimberly Shelton, Fitness/Athletic Coordinator City of Federal Way 876 S. 333r`' St. Federal Way, WA 98003 CITY OF FEDERAL WAY kip Priest, Mayor Date: � � Z� �l �� � -1- ATTEST � Carol McNeilly, CMC, ity Clerk HEALTH CARE PROVIDER ���-� �...�. � . � "�� (Signature) ,--- �'' �,�rrY 2 � . �o�/ �V'�..�,,-�,. � �� �" � P �� � S c��" (Printed Name and Title) � � �/�v�� ,��. (�'�a s �-...�.. � �� z � C'�-„��'2,., (Organizatton Name) 1 \ �..�` � � � v�� �`�VQ ... (Address) � UL.Q �� �-�;c � � one) Date: 1 � STATE OF WASHINGTON ) ��N ) ss. COUNTY OF � \� `���"�,��'„ V�� j ��l�l On this day personally appeared before me ��,�.��N��, �,o�,�' �''t , to me known to be the ��C,.nrr�A Yt���y����i � of V_ 12TIn(j/�'lY1�NIY�t�tt'AL.G�#'n/TC2 that executed the foregoing instrument, and acknowledged the said instrument to be the free and voluntary act and deed of said corporation, far the uses and purposes therein mentioned, and on oath stated that'1�[she was authorized to execute said instrument and that the seal affixed, if any, is the corporate seal of said corporatian. GNEN my hand and official seal this � day of ,..J �U� , 2013 . �,�NN\t111{�Ey�� �.. • --�� � g, � �R�, Notary's signature r ��`a�`�"�•M",+��, °'+,, Notary's printed name . . �p� ��f'�•,4'� Nota�y Public in and for the State of Washington. ��'fr�i ��" !� �_ , _� �� % My commission expires 3 -'aL$•�II✓/l'o �,� '`v��.��` � � ►y', �'�`�'N,�,; �a,�'`°.: ���e°� w►+�`'``:..�� K:Wgreements\Parks120{01Health Fair Indem -2- TE(�FI �rginia Mason Health System P.O. Box 900, G1-PS 1100 Ninth Avenue Seattle, WA 98111 P: (206) 583-6007 F: (206) 515-5899 Effective 05/31/2012 Virginia Mason Health System's Self-Insured Professional Liabitity Program covers the employees of Virginia Mason Health System while acting within the scope and during the course of their employment with Virginia Mason Health System, for all acts that are normally covered by customary general and professional liability insurance policies. This program is continuous and does not expire; however, termination of employment terminates coverage. Additional Insureds include students, employees and authorized volunteers when working for Virginia Mason Health System within the scope of their duties. This includes employed interns, externs, residents, certified registered nurse anesthetists, physician's assistants, dentists, osteopathic physicians and surgeons, physicians, podiatrists and surgeons, when working within the scope of their duties for Virginia Mason Hea�th System. General and Professional Liability: CommerCial General Liability, Medical Professional Liability Contractual Liability Because this is self-insured by Virginia Mason Health System there is no "policy number" General Aggregate Products - Comp/Op Agg Personal & Adv Injury Each Occurrence Fire Damage (Any one fire) Medical Expense (Any one person) $ NIL $ Included $ 1,000,000 $ Included $ N/A Coverage provided by Virginia Mason Health System's Self-Insured Program is continuous and applicable to all general and professional liability claims occurring while the Virginia Mason Health System employs the provider irrespective of when a claim is made. Event Name: Federal Way Health & Safety Fair Physical Location of Ever�t: Federal Way Community Center; 876 South 333 Street; Federal Way, WA 98003 Date of Event: January 26, 2013 10:am - 2:pm Certificate Issued with express authorization of Virginia Mason I 7his document is oonferred as information ony, does noc arter Health System, Manager, Risk Fnancing & Claims. coverage afforded by the Self-Insurance Plan in any way, and guarantees the holder no rights beyond those extended in the policy. certiticate issuea i o: City of Federal Way 876 South 333rd Street Federal Date Issued: 12/17/2012 LM/sbw , WA. 98003