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AG 13-031RETURN TO: EXT: �n�.i � ; �: CITY OF ��DERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT./DIV: 1" � -S 2. ORIGINATING STAFF PERSON: 1 EXT: C�I� �jZ- 3. DATE REQ. BY: I�% II.3 �1m�t. -(�� � 4. TYPE OF DOCLJMENT (CHECK ONE): n0 �'���- ❑ CONTRACTOR SELECTION DOCLTMENT (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 ❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT (E.c. sorm xEE1.nTEn nocvMENTS> ❑ ORDINANCE ❑ RESOLUTION ❑ CONTRACT ENDMENT (AG# : ❑ INTERLOCAL I� OTHER �0.I� �Cl.[ ✓ ��I ���'��-g��iriv► �Y3'Vl�� ��% � 5. PROJECT NAMI 6. NAME OF CON ADDRESS: E-MAIL: SIGNATURE NAME: FAX: TITLE 7. EXHIBITS AND ATTACHMENTS: ❑ ScoPE, WORK OR SERVICES ❑ COMPENSATION � INSURANCE REQUIltEMENTS/CERTIFICATE ❑ ALL OTHER REFERENCED EXHIBTfS ❑ PROOF OF AUTHORITY TO SIGN O REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS 8. TERM: COMMENCEMENT DATE: I�2�0 � l3 LO U-IM- COMPLETION DATE: � I�o � l 3 Zb,M 9. TOTAL COMPENSATION $ (nlcLUnE ExP�vSES nNn s.aLES Ta�x, � a�rrY) (IF CALCULATED ON HOURLY LABOR CHARGE -ATTACH SCHEDULES OF EMPLOYEES TTfLES AND HOLIDAY RATES) REIMBURSABLE EXPENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX OWED ❑ YES ❑ NO IF YES, $ PAID BY: � CONTRACTOR ❑ CITY ❑ PURCHASING: PLEASE CHARGE TO: 10. DO ENT/CONTRACT REVIEW I1�TITIAL / DATE REVIEWED\ I1�IITIAL / DATE APPROVED ROJECT MANAGER `�� � � 4 � ���� N L\� �� DIRECTOR � -��i �I LAW I � �l �D[3 1 t�28I?Ui3 � � — S�� K�s Vo oivl— 1.2 • � 11. COUNCIL APPROVAL (IF APPLICABLE� COMMTTT E APPROV L DA ' COUNCIL APPROVAL DATE: 12. CONTRACT SIGNATURE ROUTING ❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D: ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS ❑ LAW DEPARTMENT j�( SIGNATORY (C1vt oR nmEC'['oR) �CITY CLERK ASSIGNED AG# I�Q SIGNED COPY RETURNED IIVITI DATE SIGNED �,�. I ?�?•l� AG# �D�� DATE SENT: I. co�Errrs: �oC4M.� �� N� b�� �-�' ��(.�nfi I✓1 pG�,S-I-'P�'�� -. �'�'�� .,� 11/9 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�G �� Way, a Washington municipal corporation ("City") and ��pS Cc� db�i �t.1,► ixUNi;�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. 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 1 l, 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, ayor Date: ��Z`� �� 3 -1- ATTEST Carol McNeilly, CMC, City Cler HEALTH CARE PROVIDER � �� �"_-� �-- -----� -'��_ � � ---___ (Signature) �� r� ��Q r-� � t... 1 l � i�. , 0 i.-�►t� �� (Printed Name and Title) --� �, � � e � � / O � J ✓a-GI�� G c�,� �� , (Organization Name) 1 Z � '1 � , '� � � `�'` � � �' �I- � � 3 (Address) a5 3�-3� ��o% (Phone) Date: � "- � `' � �� STATE OF WASHINGTON ) ) ss. COUNTY OF � {� `-G O` � r Ga..� . W {O � W � �� ✓�� � On this day personally appeared before e j}�-� h-2 v� �q �� to me known to be the �(� J n�e r of �� I I �n i�' �- � C' _ e a" that executed the foregoing instrument, and acknowledged the said instrument 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. GNEN my hand and official seal this � day of JGt,v�. , 201�. Notary's signature �- � � M. G. P I Z Z I�TB� i C Notary's printed name - 9' NpTARY P � ' STATE OF WASHINGiOhf Notary Public m and for the State of Washington. COMMiSS{QN EXPIRES My commission expires �/-1 q' --/(o APRIL 19, 2016 K:�Agreements�Parks�2010�Iealth Fair Indem -2- . . AC�I�DTM C�RT�FICATE (3F LIABILITY INSURANGE °"T�'�"°°^"' 01-09-13 �°O�� TH15 CEHTIRCATE 1S ISSUED AS A MATTER OF INFORNIATION �()RTHEAST AGENCIES INC. ONLY AND GONFERS NO i�l(dHTS UPON THE C£RTIFlCAlE HQLDER, 'f7iIS CER'IIFICATE DQES N4T ANEND, FJ(iENp OR 301 waods park drive AI-TER T1iE COV�RAG£ AF�RDED BY TF{E POLICIES BELOW. �linton, NY 13323 _ 0 a�URERS AFFORQING COVERkGE �. �,� - - - - - r+tsu�a a: DCPS CORP. DBA BALL CHIROPRACTlC CENTER �vs��B: �717 SOUTH 324TH ST STE B ' ivsu�RC: FEDERAL WAY, WA 98003 �NSU►�aa: 1'HE PQLtC1E3 OF IN3URANCE LISTED BELOW HAVE BEEN ISStJEd 70 TNE INSURED NAMED A$OYE PDR?HE PQLICY PERIOD INDICATED. NOTUY[TH3T,4NDING - 4NY RE�UIREh�ENT, TERM OR GONOffIQN OF ANY OONTRACT OR 01HER DOCUMEN7 WiiH RESPEC'r i'�0 WWICH THIS CERTIFICATE MAY BE ISSUED OR NAY PERTAIN. THE INSURANCE AFFORDED BY lHE POLiC1ES DESGRIBED H�AE1N IS SUBJEGT 70 ALL 7ME TEAMS, EXCLUSIOnS ANO CONDI710NS dF 5L1CH 'a.ICIaS. AGGREGATE LIM�TS SHpWN MAY HAVE BEEN REDUCED BY PAtD CLAIMS. NiERGAL QENERAL LIABILIiY CLAMY6 NkADE a pCCUR � --- --' -- --- - .. .. ... .......-- 'L AGpRECiATE LII�7APPLIES PER: PRU- ��,�., POLlC1 � •lFiiT J _l— oiuro�� u�wrr ANY A:iTO ALL OH7VE0 AUTQ8 SCtiEDULEO AUTO$ HIRED AUTOS NON-0WiJE� AUTOS OAitABE 1JA61L17Y ANY AUTO i _ � EXCFSS LIABILfiY OCC�JR � CLAIMS NNOE DED'.1Cri8LE _ Re'rervrwn j WDHKERB COMP�J1710N ANO 9NPIAYEAB' LJA61LI7Y � eaai oocu�NCE i s ' flae o�w�►oF tu,y ane we� s Q 15BAAW6327 0't -07-13 01-07- 9 4 MED EXP (Ady ona persan) ; s PEqSONAL&ADV W,FURY S �� ciHdL�tAl. nooFlEOME S PROOUCTS - COMP/OP A[iCi S Ol'F1ER O 3CqP71QM OF OPERAT{pVSl1.00AT10![SNE�pGCLUgqWg Ap�bBY ENDOR$EMENTISpEpAL PROVISIONS �'hose usual to the Insured's operat�ons C iRT7FlCATE wOLbER l i��o� �� �ITY OF FEDERAL WAY 33325 8TH AVENUE SOUTH =EDERAL WAY, WA 9$003 � A :DRD 25�S (7197j — caneiNeos�nrc�� uMrr ' a (Ee accidsM) BODIIY O�UJRY S (Perperson} BODILY rIJURY s (Peracddent) PROPERiY DAMAQE ; (Peraetldat} AUTO QN_Y - EA ACCIDEMT i OTH�iT�iAN EAAGG S AUfOONLY: � S EACH OCCURRENCE S E.L. 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