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AG 13-028TO: CITY OF 1. ORIGINATING DEPT./DIV: EXT: r�. � �� �, ERAL WAY LAW DEPARTMENT ROUTING FORM (�� S 2. ORIGINATING STAFF PERSON: 1 � JVl EXT: V� J� 3. DATE REQ. BY: I'�/ I� ��� ���.� 4. TYPE OF DOCUMENT (CHECK ONE): �0 ��� ❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP; RFQ) � J� i) 3 ❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT 1 l ❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT ❑ GOODS AND SERVICE AGREEMENT O HUMAN SERVICES / CDBG ❑ REAL ESTATE DOCLJMENT ❑ SECURITY DOCLJMENT (E.c. soxn xEiaTEn nocvMENrs� ❑ ORDiNANCE ❑ RESOLUTION ❑ CONTRACT NDMENT (AG# : ❑ INTERLOCAL f � OTHER �I-{� FCL [ ✓ �✓t � j��[1�1��C1' a�Zd� �Y1'V�g 1 � � 5. PROJECT NAME: �,j/V� � � W �--� �.-�-� -f- �-Ir�� �.� 6. NAME OF CONTRACTOR: ADDRESS: E-MAIL: SIGNATURE NAME: FAX: TITLE 7. EXHIBITS AND ATTACHMENTS: ❑ scOPE, WORK OR SERVICES ❑ COMPENSATION � INSURANCE REQUIItEMENTS/CERTIFICATE ❑ ALL OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORTTY TO SIGN ❑ REQUIItED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS 8. TERM: COMMENCEMENT DATE: � f 2.Cv 1[3 I,O � COMPLETION DATE: I l Zf'o � i 3 Zb,A,t 9. 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: O�s ❑ xo IF YES, MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX OWED O YES ❑ NO IF YES, $ PAID BY: ❑ CONTRACTOR ❑ C1TY � PURCHASING: PLEASE CHARGE TO: 10. DO ENT/CONTRACT REVIEW II�iITIAL/DATEREVIEWED INiTIAL/DATEAPPROVED ROJECT MANAGER °�,� I t') I� t, �'I�� �3 DIRECTOR �— G�?�rI£P�-{���c�� �I LAW ( i� j�013 � 1 �28��ot3 " S G�� �0�'S yp ��j-' 1.� • I 11. COLTNCII.APPROVAL(IFAPPLICABLE) COMM EAPPROV LDA ' COUNCILAPPROVAL ATE: 12. CONTRACT SIGNATURE ROUTING ❑ SENTTO VENDOR/CONTRACTOR DATE SENT: DATE REC'D: ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS ❑ LAW DEPARTMENT �( SIGNATORY (CM oR nu�C�rox) �CITY CLERK ASSIGNED AG# f�J SIGNED COPY RETURNED I1�TITI DATE SIGNED � ��a-! � � ��' �•� AG# ��j -�� DATE SENT: 1 • � - j � -o ..�� � .,-.�,..... „ �_ _ . . t . , r � 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 t1�e City of Federal Way, a Washington municipal corporation ("City") and o�� � , 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 of�icials, officers, employees, agents, volunteers, sponsors, contributors and donors harmless from any and a�l 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 Caze 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 sha11 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 Shelton, Fitness/Athletic Coordinator CiTy of Federal Way 876 S. 333rd St. Federal Way, WA 98003 CITY OF FEDERAL WAY �� Skip Priest, ayar Date: `� Z`� � � -1- ATTEST � Carol McNeilly, CM , City Cle k .. G� HEALTH CARE PROVIDER ignature) �Rr C.� �hl2hh " � � ✓ e c�'o(' (Printed ame and Title) �ll�` V 0.✓1 �2Ar v�� v�.q (Organization Name) �2��� I�O�A�e. S �s�. Z�-e�.v'o�t li.�a�s.1 i�o03 (Address) Z53 •`c�3�3 • C�c�'7 (Phone) � Date: 1 �3 f 13 STATE OF WASHINGTON ) � ) ss. COUNTY OF �. On this day personally appeared before me �t1�'GV �1%L�o� , to me known to be the I�;r2��2, of I�,. Lp� �,��,., r� that executed the foregoing instrument, and acknowl de ged the said instrumen be the free and 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. GIVEN my hand and official seal this �� day of � , 201.3. ,,�„��,r,,,�►�. Notary's signature `�YYtu'r'Y l�.e� �° �?�t-�`""f d" �� Notary' s printed name �t c� r�-!-� � L, N1a✓�� �-1 St�e oi wah�nptan Notary Public in and for the State of Washington. �� � ��Y My commission expires � S - Ol - �-� �5 �y AppoNibn�M Exphes Ma�r 1, 2015 K:�Agreements�Pazks�2010�IIealth Fair Indem -2- � '��..� OP ID: J �'`;�OR°� CERTIFICATE OF LIABILITY INSURANCE DA���Dmrn 01/16/13 THIS CERTIFICATE IS ISSUED AS A AAATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETVYEEN THE ISSUING INSURER(Sj, AUTHORIZED REPRESENTATNE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subJect to the terms and conditions of the policy, certaln policies may require an endorsement. A st�emerrt on this certfflcate does not confer rigMs to the PRODUCER Irrtermarket Insurance Agcy Inc t05 E Main Street, Suite 3d Hunt��7ton, NY 77743 ndsu�o Darcy Webb dba Sylvan Learning Center 327171 st Avenue South Federal Way, WA 98003 631 �27 -242 " ' 631 �21-20 PHO No Y : , aoo�ss: . S-WEBB1 INSURER{S) AFFORDING COVERAGE a�suaeRa: Travelers Indemni of America wsur�Re: Philadel hia lns Com nies irnsu�x c : Q4SURER D : INSURER E : s 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 REQUIREMEMT, TERM OR CONDITION OF AM' 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 SHOYVN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R�ISR TypE OF INStlFtIWCE POLiCY N h�ER L�$ GENERAL LU181LRY EACH OCCU2REIVCE S ���� A X COMXv1ERCIALGEt�RP1LIABILITY 80�76H4991-TIA 1�12 12128/73 p EMIS S Ea e $ �� CLAIiv�-MADE �X OCCUR �D � t�Y � Pe��l S 3� PERSONAL & ADV INJU2Y s 'I �OOO� GEI�RHL P�GGREGATE S ���i GEML AGGf�GATE LIMIT APPUES PER: PRODUCTS - CO�AP/� AGG i Zr�i POLICY P� LOC O G8 � p�pMppq� L�Ry CON�II�D SINCaLE LIMIT S ,� �0�� A nr�vnuro 680�76H4991-TIA 12I28H2 72l28h13 �Ea�q`�� BODILY INJlN2Y (Per person) S ALL OWNED AIJfOS BODILY INJURY (Per ecci�} ; SCHEDULED AUTOS PROPERTY DAMA6E X HIRED AIJfOS (Per ecciderd) s X NON-OWI�D AUTOS $ S �u.a uae X�cuR encH occ�rx� 1 ���� EXCESSLWB CLAIMSMADE AGGREGATE f ��� A UP�67 ST406 12128H 2 12J28/73 DEDUCTIBLE $ X NTION .r1�0 WOWCER8 COI�ENSAl10N X AI� EMPLOYERS' LIABaIfY - /01 ANYPROPRIETORIPARTNERIEJCECUTIVE Y❑ N!A 680-b76H4991-TIA 12l28h2 i71�1�$ E.L.EACHACCIDENT $ ���r OFFICERIMEMBER EXCLUDED? {Mandatory In I�Mi) STOP GAP LIABILITY E.L. DISEASE - FA EMPLOY t 7,�, If yes, describe under E.L. DISEASE - POLICY LIMIT � OOO g prof uabipty PHSD581017 01/01113 01/01J14 ClairrJAgg �1MfU 1Mi p e/Molestatlon 880-578H4991-TIA 1?128h2 72t28/13 CtaimlAgg S1AAiUS2Mi DEBCRIPTION OF OPERA710NS I LOCA7WNS / VEFRCLES (Attach ACORD 101, Additlond Rsmarks SeMduls, M moro sp�s Is roquin� r�e��u►wr� un� n�o reur�� i er�nm City of Federal Way 33325 8th Ave S Federal Way, WA 98003 CTYFEDE SHOIAD ANY OF THE ABOVE POLICIES BE CANCELLED B�FORE THE EXPIRATION DATE TNE�DNOTICH YMLL BE DEI.NERED N ACCORDANCE WITH THE POLICY PROVISIONS. AUiHOR1�D REPItESENTATNE � T` O 1988-2008 ACORD CORP�RATION. All rights resened. ACORD 25 (2008/08) The ACORD name and logo are registered marks of ACORD