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AG 13-030To: ��il����l r�1 � � . ExT: �'1 �� �..1 CITY OF ��DERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT./DIV: 1" � � 2. ORIGINATING STAFF PERSON: i � � �M EXT: V� �J� 3. DATE REQ. BY: ��i �U 4. TYPE OF DOCUMENT (CHECK ONE): ��� ��� � no ��-�-�- ❑ 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 ❑ GOODS AND SERVICE AGREEMENT ❑ HUMAN SERVICES / CDBG 6. ❑ REAL ESTATE DOCUMENT ❑ ORDINANCE ❑ CONTRACT � OTHER � ❑ SECURITY DOCUMENT (E.c. aorro xEr,n�n nocun�rrrs� ❑ RESOLUTION ❑ INTERLOCAL _ 1.... � . _. PROJECT NAME: �.j/VI < < v+ l�-i-i� -i- �-I;-��. �f,� NAME OF CONTRACTOR: ADDRESS: E-MAIL: SIGNATURE NAME: TELEPHONE FAX: TITLE 7. EXHIBITS AND ATTACHMENTS: ❑ SCOPE, WORK OR SERVICES ❑ COMPENSATION � INSURANCE REQUIItEMENTS/CERTIFICATE O ALL OTHER REFERENCED EXHIBTTS O PROOF OF AUTHORITY TO SIGN ❑ REQUIItED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS 8. TERM: COIvIMENCEMENT DATE: I/�-<o r t 3 LO CCtNI COMPLETION DATE: 1!�f'o � i 3 Z taM 9. TOTAL COMPENSATION $ � (INCLUDE EXPENSES AND SALES TAX, IF ANY� (IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPIAYEES TTTLES AND HOLIDAY RATES) REIMBURSABLE EXl'ENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX O WED ❑ YES ❑ NO IF YES, $ PAID BY: � CONTRACTOR � CITY ❑ PURCHASING: PLEASE CHARGE TO: 10. DO NT/CONTRACT REVIEW ROJECT MANAGER DIRECTOR ����e� �I LAW � ����Q13 � t�ZS,�ol3 11. COLTNCILAPPROVAL (�' �PLIC.�s�) IIVITIAL / DATE REVIEWED IriITIAL / DATE APPROVED `I�'�'.,� I �-, ! 3 l� � il�l.l : �it�!�� l. ,1.1 � 1 / /1 l� Ii�l �.�i.�l�1�� ! '' ► ► ' � �� ' : • '• �• � • i '• � 12. CONTRACT SIGNATURE ROUTING ❑ SENTTO VENDOR/CONTRACTOR DATE SENT: DATE REC'D: O ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBTTS ❑ LAW DEPARTMENT �( SIGNATORY (cM ox DmEC�roR) � CITY CLERK �ASSIGNED AG# �' SIGNED COPY RETURNED I1vITI DATE SIGNED i �� ���' �� AG# l3 - D?� DATE SENT: I " �iD • I � • I ' ���( > � ��� � � f �j r � � INDEMNIFICATION AND INSURANCE AGREEMENT This indemnification and Insurance Agreement ("Agreement") is dated effective the later date indicated below with the signatuxe. The parties ("Parties") to this Agreement are the City of Federal Way, a Washington municipat corporation ("City"} and .�n /Vt[� (�e�Yt �a�/ ,. a {"Health Care Pmvider"). �' � �� G. A. The Health Care Provider wishes: to cantribute services for the Federal Way Family : . : . . :.: .:. . :. � : Health.& Safety Fair on 7anuary 26, 2Q13; `and _ . � ::' .' . � : . : ; . , ` � . :. �� `� B. The City wishes to coaperate by allowing the use of the Federal Way Co wu Center, , 876 S. 336�' Street, Federa! Wa , Washi on: �� �e-i:s'.fr5. .: cM � r�� �-� 2:;1���leo� Y � . �P �% '� .. . . NUW, THEREFORE, the Parties agree as follows: �, �� 1. Indemnification. In consideratian of the City authorizing �ts use of the Federal Way Community Center, the Health Provider agrees to indemnify and hold the City, its elected officials, afficers, emplayees, agents, volunteers, sponsors, contributors and donors harmiess from any and all claims, demands, Iosses, actions and liabilities {including costs and all attorney f�s) ta or by any:and all persons or entities, including, withaut iimitation, their respective agents, licensees, - or represent�tives, arising from, resuiting from, or connected with this Agreement or the use of the Federal Way Community Center or relating to the Family Health & SafeEy Fair ta the extent :caused by the acts, errors or omissions of the Health Care Provider, its partners, shareho�ders, agents, employees, invitees ar by the breach of this Agreement. 2. Insurance. The Health Care Provider agrees to submit. a. Certi.ficate. of insurance evidenciag Commercial General Liability in the amount of no less than $1,040,000 naming the City of Federal Way as additionat insured and Professional Liability insurance in the amount of no less than $1,OOU,000. The Certificate should be presented with the executed Agreement no Iater than Friday, January 11, 2013. Failure to submit proaf of such insuranee and execute this Agre�ement. shall prohibit the Health Caze Provider from participating in the Federat Way Community Center : : : : . :. :.. .. :. Health Fair on Janua.ry i 1, 2013. .`.: '. . . .: 3. City Contact. Submit the certificate afinsurance and the executed Agreement no later than Friday, January 11, 2013, to: Kimberly Shelton, Fitness/Athletic Caordinator City af Federal Way 876 S. 333r� St. Federal Way, WA 98003 : .. � .:: . . :. : . .:....:.. . ... ::.... :.. : ... �..: ..-.:.. CITY OF FEDERAL WAY � Skip Pries , Mayor Date: � � 2�� � I � -1- ,. .. . . � . ,.. . . � ; ;.�; . : ATTEST � � . .:. .,; . . . r :�r� � : , ° :: . . .. . . . .. . . ;�. .. . ..., ... 11 �-'..,.� Carol McNeilly, CM , City Cler HEALTH CARE PROVIDER , ll i!J (Signa g�G�th C�'tX�,IG�l�, �X'� 0�5��� ��tV�I�tfeG-f��' (Printe ame and Title) Q{� Qjel'l(,I f C1 � CI�1(,t}, IQ,d W- OeC�'1��, ' �� C�.�1 C�LIi �p C 11� C. Or acuzation Name l�J�! � g ) 21.� �1 S�- �e 1� � , Ui/� °1�1 tY�l (Address) �2c� t�� 4 41 t� S (Phone) Date• �1 3 C�r�uu-� 1�/P�'f (Jfvt��`�� �C��?�t/� V1�.2 � � STATE OF WASHINGTON ) ) ss. COUNTY OF ` On this day personally appeared before me 'g eC�2�1� c�,� , to me known to be the �p.f'��„��i�e_ �;�'P�-1t„2 of !�me¢:�r�. �,c.e�e Sauc� ___that executed the foregoing instrument, and acknowledged the said instrument to be he free and voluntary act and deed of said corporation, for the uses and purposes therein mentianed, 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. C3IVEN my hand and official seal this �Dy�, day of \,�ua,2u� , 201�. JENNIFER M. WHIP NOTARY PUBLIC STATE OF WASHIN�TON C4MMISSION EXPIAES JUIY 29. 2016 K:WgreementslParics12010�Health Fair Indem Notary's signature �1-C/ � Notary's printed name � � Notary Public in and for the State of Washington. My commission expires� .1.a aq, ao I lo -2- � 139199 ;a►co � CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDWYYYY) ��. 1/10/2013 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 pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subje�t to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate dces not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER N�E � Mdy Adams Commercial Lines —(404) 923-3700 P�NE . 404-923-3526 F� 877-362-9069 No : Wells Fargo Insurance Services USA, Inc. A��ss, andrew.adams@wellsfargo.com 3475 Piedmont Road NE, Suite 800 nrsuR S AFFORDING COVERAGE rwc s AUanta, GA 30305-2886 iNSURERA: Federal Insurance Company 20281 ���� iesur�e s: Pacific Indemniry Company �� American Cancer Society, Inc. iNSUr�R c: 2� WIII8fY1S SU'8e1 INSURERD: Atlanta, GA 30303 COVERAGES CERTIFICATE NUMBER: ��`�26 REVISION NUMBER: See bebw 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 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. �SR TYPE OF INSURANCE �DL SUBR p�uCY NUMBER �LICY EFF POLICY EXP � UM� LTR A (iENERAL LIABILITY 35943463 09/01/2012 09/01/2013 F=CH OCCURRENCE E �.�•� X COMMERCIAL GENERAI LIABILI'iY PREMISES Ea s �•� CLAIMSMADE � OCCUR MED EXP (My one peteon) E 2.500 PERSONALBADVINJURY S �•��� C,ENERAL AC,GREGATE i Z5.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S 2���� X pp�ICY PRO- �� S q �uTOMOS�� u�urr 73563471 09/01/2012 09/01/2013 �Ble�ntSINGLE LIMIT t�� X ANY AUTO 73563476-PUBPfA RIOO BODILY INJURY (Per peraon) E ALL OWNED SCHEDULED 73rJs�,77-H8W811 � BODILY INJURY (P� acddeM) S AUTOS AUTOS pROPERTY DAMAGE E NON-OWNED per axid t X HIRED AUTOS X AV7pg E UMBREILA LU1B �C�R EACH OCCURRENCE S EXCESS WB CLAIMS-MADE AGGREGATE S DED REfENTION ; B��� pr���w�siromr 71741355 09l01/2012 09/01/2013 X WCSTATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y, N E.L. EACH ACCIDENT E �'�'� OFFICERlMEMBER IXCLUDED7 � N � A (�ay M N� E.L. DISEASE - EA EMPLO S �'�'� DE3CRI� OF OPERATIONS bebw E.L. DISEASE - POLICY LIMIT S �•�'� DESCRIP710N OF OPERATIONS / LOCATIONSJ VEHICLES (Atlach ACORD 701. Additional Rsmarks Schedule. If more space is re�ired) Certificate holder is induded as an additionai insured in aocordance with the terms and c:onditions of the generai liability policy. Re: Booth at Federal Way Community Center Family Heal� and Safety Fair on 1/26/13 10am - 2pm at Federal Way Community Center - 876 S 333rd St Federal Way, WA 98003. �C�ITS� 7 City of Federal Way Kimberly Shelton 876 S 333rd St Federal Way, WA 98003 ACORD 25 (2010/0� SHOULD ANY OF THE ABOVE DESCRIBED POLICIE8 BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE YVITH THE POLICY PROVISIONS. AUTNORIZED REPRESENTA7NE 9«�l�- -- 7'he ACORD name and Iogo are regis�red marks of ACORD m 1988 2010 ACORD CORPORATION. AII rights �erved.