Loading...
AG 13-029�TU�vTO: �,�6��i1,� � � . ExT: �9 t�� CITY OF ��DERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT./DIV: 1" � � 2. ORIGINATINGSTAFFPERSON: i ;�V1Q��� EXT: ��-/� 3. DATEREQ.BY: I�/ �� �.Im�t -FP,�� Ic�c�- 4. TYPE OF DOCUMENT (CHECK ONE): �O �� ❑ CONTRACTOR SELECTION DOCUMENT (E.G, RFB, RFP;-RFQ) (�� i� 3 ❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT � ❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT ❑ GOODS AND SERVICE AGREEMENT ❑ HUMAN SERVICES / CDBG ❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT (E c soxn xEEr.,e,TEn nocuMErrrs� ❑ ORDINANCE O CONTRACT l� OTHER � ❑ RESOLUTION ❑ INTERLOCAL � ` � 5. PROJECT NAME: �.j/V� l� v1 1�..� -�- �Y:c �k--P� zJ�. ��.� 6. NAME OF CONTRACTOR: ADDRESS: r;-MA1L: FAX: SIGNATURE NAME: TTTLE 7. EXHIBTTS AND ATTACHMENTS: ❑ scorE, WORK OR SERVICES ❑ COMPENSATION � INSURANCE REQUIREMENTS/CERTIFICATE ❑ ALL OTHER REFERENCED EXHIBTfS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIItED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS 8. TERM: COMMENCEMENT DATE: I f Z�Co ( t3 IO U,ta/L COMPLETION DATE: I?� C[ 3 'Z 9. TOTAL COMPENSATION $ f� (INCLUDE EXPENSES AND SALES TAX, IF ANY� (IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLAYEES TITLES AND HOLIDAY RATES) REIlVIBURSABLE EXI'ENSE: ��s ❑ xo IF YES, MAXIMUM DOLLAR AMOUNT. $ IS SALES TAX OWED ❑ YES ❑ NO IF YES, $ PAID BY: ❑ CONTRACI'OR O CiTY ❑ PURCHASING: PLEASE CHARGE TO: i0. DO ENT/CONTRACT REVIEW ROJECT MANAGER DIRECTOR ��+I�A}'�f {�-��c� �J LAW i l�(2a��, ��.�s��o� 11. COIJNCII.APPROVAL (g' nrPLIC.4sr�) I1�iITIAL / DATE REVIEWED I1�TITIAL/ DATE APPROVED ��� ! 1 �T 3 ��T :tA�� : �t�"��_r .�.r � � � � i !►�7 � ��'��."'�l'iri �� , �, , , ' � ` � •c� = • �• ��+ • i �• � - 12. CONTRACT SIGNATURE ROUTING ❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D: ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS ❑ LAW DEPARTMENT � SIGNATORY (CM ox nm�cTOR) CITY CLERK ASSIGNED AG# '� SIGNED COPY RETURNED II�1IT DATE SIGNED I • 30-13 AG# �� � �[ DATE SENT: I' � °I�� nnw.n�,r�.rro. n _ _ t. m _. _, _ � 1 _ _ , , �' INDEMNIFICATION AND INSURANCE AGREEMENT This Indemnification and Insurance Agreement ("Ageement") is dated effective the later date indicated below with the signature. The parties ("Parties") to this Agreement are the City of Fede� al �, Way, a Washington municipal corporation ("City") and «�c� }-}vrVl2C�l � v�.G �ba C� ("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. 336th 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 1 l, 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. 333`d St. Federal Way, WA 98003 CITY OF FEDERAL WAY Skip Prie , Mayor Date: , �Z �1 � � � -1- ATTEST � Carol McNeilly, CMC City Cler � HEALTH CARE PROVIDER � (Signat e) �i m h� � S�t,h d� �eZ O ls� n-er (Printed Name and Title) �AVv�-Frr � e s (Organization Name) 2-F�c �— Pa c� ��-I-u� ,S. 5��, ��A� I=� a� e�a� (� , G�.� Q g o a3 � � (Address) �3 -��-1 �o � (Phone) Date: � � � � r � STATE OF WASHINGTON ) ) ss. COUNTY OF � On this day personally appeared b fore me /��,iy� �,c'�� �`,�1e c I to me known to be the � /,v�v � cQ of �m ..� � � ,P .� ,P S that executed the foregoing instrument, and acknowledged the said mstrument to 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 , 20�. NOTARY PUBLIC STATE OF WASHINGTON NANCY � �A��ON My Appointment Expires May 17, 2015 K:�Agreements�Parks�2Ol0�I-Iealth Fair Indem Notary's signature �y ��Cu � �����_ Notary's printed name ��q.. l�� ��o�� Notary Public in and for the Stat of Washington. My commission expires �`- / %'-��D/S —2— .• '. ,d►c-oR°' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YWI� `� 1/15/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S�, AUTHORIZED REPRESENTATIVE 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, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in Iieu of such endorsement(s). PRODUCER SilverStone Grou NAME: P PHONE FAX 11516 Miracle Hills Drive ac No �: �uc No: Omaha NE 68154 no�ess: homecare@ss i.com PRODUCER Cl13TOYER ID #� BIANC- 1 INSURED Bianchi Home Care Inc. dba Comfort Keepers 28815 Pacific Hwy. S. Suite 7A Federal Way WA 98003 INSURER A : IN8URER B : irrsuReR c • INSURER D : AFFORDING COVERAGE PIAIC il COVERAGES CERTIFICATE NUMBER:334707584 REVISION NUMBER: THI.S IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO'iWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 'ryPE OF INSURANCE POLICY EFF POLJCY EXP UN� LTR POLICY NUMBER MMID M A ��p�.�,�pg���Ty PHPK874646 7/1/2012 7/1/2013 EqCH OCCURRENCE $1, 000, 000 COMMERCIAL GENERAL LWBILITY PREMISES Ea o�rrer�ce Sl, 000, 000 CLAIMS-MADE � OCCUR MED EXP (My one person) $20 , 000 PERSONAL&ADVINJURY Z1,000,000 GENERALAGGREGATE 52.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG =2. 000, 000 POLICY PR� LOC S A AUTOMOBILELIABILITY PHPK874646 7/1/2012 7/1/2013 COMBINEDSINGLELIMIT g1,000,000 (Ea accideM) ANY AUTO BODILY INJURY (P� persai) S ALL OWNED AUTOS BODILY INJURY (P� acaderM) S SCHEDULED AUTOS X PROPERTY DAMAGE s HIRED AUTOS (P� ���) X NON-OWNED AUTOS s S UMBRELLA W16 �CUR EACH OCCURRENCE i �C� �B CLAIMSauIADE AGGREGATE S DEDUCTI6LE S RETEN710N $ WORKERS COMPENSATION WC STATU- OTIi- AND EMPLOYERS' LIABIUTY Y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? � N � A (MaMatory in NH) E.L. DISEASE - EA EMPLOYE $ Ifyes describe under DESCRtPTION OF OPERATIONS bebw E.L. DISEASE - POLICY LIMR S A Professional Liability PHPK874646 7/1/2012 7/1/2013 Limit $iM/$2M Property Limit Per Schedule Crime Limit $50,000 D�RIP710N OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Addltlonal Remarks Schetlule, H more space is reqWred) Certificate holder is listed as additional insured with respect to the Commercial General Liability policy. City of Federal Way 33325 8th Ave S. Federal Way WA 98003 ACORD 25 (2009/08) SHOULD ANY OF THE ABOVE DESCRIBED POIICIE3 BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE NflLL BE DELIVERED IN ACCORDANCE YYITH THE POLICY PROVISION3. AUTHORIZED REPRESENTATNE . � 1��,� � 1988-Z009 ACORD CORPORATION. AII rigMs reserved. The ACORD name and logo are regisbred marks of ACORD